Posted on Friday, August 12, 2016 4:40 PM
When auditing patient goals, progress and medical diagnosis in therapy documentation, it is especially important to check for greater specificity.
According to Jennifer Lee, rehabilitation manager for the VNA of Care New England in Warwick, R.I., “Taking a patient-centered approach to therapy services can ensure documentation provides the key information to satisfy government.”
“Changes in the information required for ICD-10 coding will force clinicians to be more specific in how they document treatment care plans and medical diagnoses,” Lee says.
Documentation in heart failure becomes a little more difficult. For example, if one is not able to determine which side of the heart is impacted, that results in inadequate physician documentation and the clinician’s limited core knowledge. “Therapists need to learn to ask the questions that provide the specificity needed to pass CMS audits,” Lee says.
“Another problem area with therapy documentation is when patients are transferred to another facility and therapy goals and progress are not clearly defined,” Lee says.
Patients need to receive proper education to move the focus from the therapist’s goals and to redirect the outcomes to where the patient is in the treatment process.
Examples of how documentation should support therapy:
• When Kami Damato, director of therapy services for Quality Home Health in Livingston, Tenn., audits charts, she is looking for the following: measurable goals, appropriate rehabilitation potential orders followed accurately for frequency, duration, interventions and timely signatures, assessments completed within five calendar days and clearly identified patient problems.
• Laurie Dennis, owner of Universal Rehabilitation, a home care therapy staffing company in Canton, Ohio, says her agency’s audit tool prompts managers to look for the time at length of therapist visits, homebound status and activities of daily living
Tips for solid therapy documentation:
• Get details needed to determine laterality
• Focus on documenting patient deficits
Corridor’s Coding Services offers ICD-10 coding, multi-level OASIS reviews, Clinician documentation review, as well as trends and reporting. Contact us to learn more.
For the full article, please see the August 12, 2016 Home Health Line Edition.
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