Rehab

Tips and tools for rehab professionals: Avoid these common pitfalls

Rehab Regs, March 20, 2009

Patients should progress and achieve the short- and long-term goals you have established with them in a reasonable amount of time. Your ongoing documentation supports the patients’ progression over this time period. The definition of “a reasonable amount of time” differs for each patient based on age, diagnosis, severity of injury/illness, and patient comorbidities, as well as many other factors.

Whatever period of time you identify for the therapy to help a patient achieve his or her goals, avoid the following common pitfalls that may lead to denials upon prospective or retrospective payment review:

  • Treatment that could be determined to be not reasonable and necessary for the condition or diagnosis
  • Services provided that could be considered repetitive in nature and not meeting the definition of skilled care
  • Lack of documentation to prove services rendered
  • Insufficient information or lack of information in the medical record
  • Billing errors, such as indicating the wrong place of service or billing for the incorrect code
  • Notes not signed/countersigned with the therapist’s or therapist assistant’s credentials

This tip is from HCPro’s book The How-To Manual for Rehab Documentation, by Rick Gawenda, PT

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