Guest guest Posted July 16, 1998 Report Share Posted July 16, 1998 Mark, thanks for providing an open forum on this big issue. a) I work as a manager in a large health system with a group of over 22 inpatient and outpatient departments. Consistency of paperwork, abbreviations, and reducing duplication of information as the patient moves through the system are some of our major challenges. With regard to clear reimbursable documentation, I have taken the following approach. We are currently updating our facility charge master and likewise online documentation and charging system. We are establish a consistent use of the CPT code description for like charges across the system both in the documentation and charging entities as well as on the charge master. We are beginning to educate our therapists in the long descriptions found in the CPT manual and recommending a " connect-the-dots " approach. By this I mean that therapist are being taught to encorporate the language of the CPT description into their clinical documentation. Thus, the note matches the bill which matches the CPT manual description. In our outpatient departments this is already proving to be in our favor with the payors. We have reduced our denials and are minimizing the chance that a first level claims reviewer can deny the claim. We have been computerized for about 4-5 years. Unfortunately the current system is TDS in that it requires entry on multiple screens to complete a note. There has been talk of updating the system to encorpate the charging and documentation systems as one. The idea being that the selection of certain " documented " words combined with time spans will trigger certain charges. To date we have not set out to accomplish this. Lane, MHS,MS,PT Rehab Manager - Operations Orlando Regional Heathcare System Orlando, Florida >>> " Mark K. Dwyer " 07/16/98 02:46pm >>> >> 1. What is the biggest issue at your facility concerning documentation from >> a) management's per perspective To be sure that what therapists document paints a clear picture of the patient's case and also justifies the provision of therapy services to third party payors. >> the staff therapist's perspective? Brevity and lack of duplication. I believe therapists are still more concerned with treating patients than with hassling with paperwork, therefore, sometimes not enough time is spent on documentation (or can be spent depending on caseload). I like the idea of moving to computerized documentation for two reasons: --> is easier to pull up past information, making note completion quicker --> is legible --> can have " required fields " where therapists MUST document --> avoids the " forget " factor >> 2. What resources are used to resolve these issues? We and many other facilties are utilizing computers to make things better. While the learning curve for computers can be steep, the ultimate payoff will hopefully be worth it in the form of decreased time demands, improved readibility, and improved standardization. >> I'm studying the topic of documentation among healthcare workers and third party payors ( primarily managed care >> organizations) and some interesting trends are becoming very apparent. I would be interested to hear about the trends you are discovering. Mark Dwyer, MHA, PT Manager of Rehabilitation Services Bethany Medical Center 51 North 12th Street Kansas City KS 66102 (Phone) (FAX) 73614.2302@... ---- Read this list on the Web at http://www.FindMail.com/list/ptmanager/ To unsubscribe, email to ptmanager-unsubscribe@... To subscribe, email to ptmanager-subscribe@... ---- Read this list on the Web at http://www.FindMail.com/list/ptmanager/ To unsubscribe, email to ptmanager-unsubscribe@... To subscribe, email to ptmanager-subscribe@... -- Start a FREE E-Mail List at http://makelist.com ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 17, 1998 Report Share Posted July 17, 1998 We are getting ready to " go live " using the Meditech computerized documentation system in my hospital and outpatient clinic. One of the nice things it does is " point of care " charging. That is a system where each charge item on my charge master has its own note. So, every day when therapists do their daily notes, they are documenting in one of these areas based on what they charged. It makes it impossible to forget to document on a charge item. It also assures that all charges entered have documentation pertaining to them. The other nice thing is it eliminates the need to complete a separate charge sheet with a billing clerk spending 2-3 hours per day keying it into the system. The only problem, however, is that therapists sometimes forget to charge the proper amount of units. So we will get to daily audits (fun, fun). Oh well, we have to take the good with the bad. Mark Dwyer, MHA, PT Kansas City, Kansas 73614.2302@... ---- Read this list on the Web at http://www.FindMail.com/list/ptmanager/ To unsubscribe, email to ptmanager-unsubscribe@... To subscribe, email to ptmanager-subscribe@... -- Start a FREE E-Mail List at http://makelist.com ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 20, 1998 Report Share Posted July 20, 1998 , I commend you on your approach, that is exactly what we teach through the annual APTA coding seminars. We encourage therapists/administrators to closely match or crosswalk their clinical services to the appropriate CPT code and do it consistently in any given provider location. We encourage therapists to utilize the nomenclature in the various codes to further describe their clinical services in the medical record. When discussing CPT codes and billing procedures with payers, this definitely gets the " thumbs up " response in terms of helping them to adjudicate the claim. Helene M. Fearon, PT Phoenix, AZ Member AMA CPT Healthcare Professionals Advisory Committee ---- Read this list on the Web at http://www.FindMail.com/list/ptmanager/ To unsubscribe, email to ptmanager-unsubscribe@... To subscribe, email to ptmanager-subscribe@... -- Start a FREE E-Mail List at http://makelist.com ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 21, 1998 Report Share Posted July 21, 1998 Question to Helene or others regarding cpt code for PT re-evaluation 97002. When is this code appropriate? And what level of documentation is expected for reimbursement? Allan B. Trumbull, Director P.T. Mount Clemens General Hospital Mt. Clemens, MI 48043 atrumbul@... > Re: Documentation > > , > I commend you on your approach, that is exactly what we teach through > the > annual APTA coding seminars. We encourage therapists/administrators > to > closely match or crosswalk their clinical services to the appropriate > CPT > code and do it consistently in any given provider location. We > encourage > therapists to utilize the nomenclature in the various codes to further > describe their clinical services in the medical record. When > discussing > CPT codes and billing procedures with payers, this definitely gets the > " thumbs up " response in terms of helping them to adjudicate the claim. > > Helene M. Fearon, PT > Phoenix, AZ > Member AMA CPT Healthcare Professionals Advisory Committee > > > ---- > Read this list on the Web at http://www.FindMail.com/list/ptmanager/ > To unsubscribe, email to ptmanager-unsubscribe@... > To subscribe, email to ptmanager-subscribe@... > -- > Start a FREE E-Mail List at http://makelist.com ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 21, 1998 Report Share Posted July 21, 1998 It has been recommended at our facility that we use this code 1)any time a patient's status has changed enough to indicate a re-eval 2)any time that the PT is reassessing the patient's plan of care and instituting new guidelines for the PTA and 3) possibly when patient's are D/C'd from subacute to Med-Surg and then return to the subacute unit within 48 hours. Any comments or other recommendations would be helpful. Tina Indianapolis, IN ---- Read this list on the Web at http://www.FindMail.com/list/ptmanager/ To unsubscribe, email to ptmanager-unsubscribe@... To subscribe, email to ptmanager-subscribe@... -- Start a FREE E-Mail List at http://makelist.com ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 21, 1998 Report Share Posted July 21, 1998 97002 PT re-evaluation is used when your patient has had a significant change that requires that you make a change in the plan of care......saying that , the documentation should include information related to the change (worse? better?) the related change in the POC and the new expected goals and outcomes...... If there is a charge for a re-eval and the POC remains unchanged, that re-eval may not be interpreted by the payer as being medically necessary. Medicare has accepted the re-eval code (was the " Q104 " ) every thirty days with documentation to support....this essentially is still the payment policy, although if the documentation supports it the carrier has paid for the service in many cases. Others payers are across the board on payment policy for this code...but the key is appropriate documentation to support the use of the code. Helene Fearon, PT ---- Read this list on the Web at http://www.FindMail.com/list/ptmanager/ To unsubscribe, email to ptmanager-unsubscribe@... To subscribe, email to ptmanager-subscribe@... -- Start a FREE E-Mail List at http://makelist.com ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 21, 1998 Report Share Posted July 21, 1998 To all, Thank you for the specifics on 97002 cpt code. Allan B. Trumbull, Director P.T. Mount Clemens General Hospital Mt. Clemens, MI 48043 atrumbul@... > Re: Documentation > > 97002 PT re-evaluation is used when your patient has had a significant > change that requires that you make a change in the plan of > care......saying > that , the documentation should include information related to the > change > (worse? better?) the related change in the POC and the new expected > goals > and outcomes...... If there is a charge for a re-eval and the POC > remains > unchanged, that re-eval may not be interpreted by the payer as being > medically necessary. Medicare has accepted the re-eval code (was the > " Q104 " ) every thirty days with documentation to support....this > essentially > is still the payment policy, although if the documentation supports it > the > carrier has paid for the service in many cases. Others payers are > across > the board on payment policy for this code...but the key is appropriate > documentation to support the use of the code. > > Helene Fearon, PT > > > ---- > Read this list on the Web at http://www.FindMail.com/list/ptmanager/ > To unsubscribe, email to ptmanager-unsubscribe@... > To subscribe, email to ptmanager-subscribe@... > -- > Start a FREE E-Mail List at http://makelist.com ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted July 23, 1998 Report Share Posted July 23, 1998 The issue of documentation has been a " hot " one for us. I manage 24 pediatric therapists (PT, OT, and ST) in both rehab and school-based settings. We have developed forms that encourage documentation of function versus merely qualitative information (which has been difficult for the therapists to discard). We have had success in obtaining TPP approval using this approach. We are interested in anyone who may have found computerized documentation for the pediatric population. Also, I inadvertently deleted the reference to the documentation publication someone mentioned. As I recall , it was written at least in part by a pediatric PT. I would appreciate someone giving me the name of it again. Lori Dominiczak, MS, PT Pediatric Coordinator Cedar Haven Rehabilitation Agency ---------- To: INTERNET:ptmanager@... Subject: Documentation Date: Thursday, July 16, 1998 1:46 PM >> 1. What is the biggest issue at your facility concerning documentation from >> a) management's per perspective To be sure that what therapists document paints a clear picture of the patient's case and also justifies the provision of therapy services to third party payors. >> the staff therapist's perspective? Brevity and lack of duplication. I believe therapists are still more concerned with treating patients than with hassling with paperwork, therefore, sometimes not enough time is spent on documentation (or can be spent depending on caseload). I like the idea of moving to computerized documentation for two reasons: --> is easier to pull up past information, making note completion quicker --> is legible --> can have " required fields " where therapists MUST document --> avoids the " forget " factor >> 2. What resources are used to resolve these issues? We and many other facilties are utilizing computers to make things better. While the learning curve for computers can be steep, the ultimate payoff will hopefully be worth it in the form of decreased time demands, improved readibility, and improved standardization. >> I'm studying the topic of documentation among healthcare workers and third party payors ( primarily managed care >> organizations) and some interesting trends are becoming very apparent. I would be interested to hear about the trends you are discovering. Mark Dwyer, MHA, PT Manager of Rehabilitation Services Bethany Medical Center 51 North 12th Street Kansas City KS 66102 (Phone) (FAX) 73614.2302@... ---- Read this list on the Web at http://www.FindMail.com/list/ptmanager/ To unsubscribe, email to ptmanager-unsubscribe@... To subscribe, email to ptmanager-subscribe@... -- Start a FREE E-Mail List at http://makelist.com ! ---------- ---- Read this list on the Web at http://www.FindMail.com/list/ptmanager/ To unsubscribe, email to ptmanager-unsubscribe@... To subscribe, email to ptmanager-subscribe@... -- Start a FREE E-Mail List at http://makelist.com ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 19, 1998 Report Share Posted October 19, 1998 I think a few of us would love to see that document. Thanks in advance for sharing. Rolando Lazaro, PT, GCS ------------------------------------------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 20, 1998 Report Share Posted October 20, 1998 I would love to have it also. I have Powerpoint. thanks. tkapusta@... > Re: Documentation > > >Does anyone have a successful flowsheet or streamlined documentation >tool that you are using in a SNF? We are looking at decreasing are >documentation time under PPS. Thanks > >Randy Titony >Executive Director, RehabSource > >Yes, I have worked out something if your interested. Do you have a >graphics >program. > > >Steve Marcum P.T. >------------------------------------------------------------------------ > >2X 2X 2X DOUBLE REWARDS POINTS! 2X 2X 2X >Open a new NextCard Internet Visa account with a >qualifying balance transfer and you'll earn DOUBLE >Rewards points. Earn free airline tickets in half the >time! Intro rates as low as 2.9% APR and NO annual fee! >Apply Online NOW! >http://ads./click/63/0/nextcard > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 20, 1998 Report Share Posted October 20, 1998 I would love to see it as well. I have Powerpoint. Thanks! ^^^^^^^^^^^^^^^^ Todd Cepica, P.T. Assistant Director Physical Medicine and Rehabilitation University Medical Center Lubbock, Tx 79417 Ph: Fax: ntc@... Re: Documentation > > >Does anyone have a successful flowsheet or streamlined documentation >tool that you are using in a SNF? We are looking at decreasing are >documentation time under PPS. Thanks > >Randy Titony >Executive Director, RehabSource > >Yes, I have worked out something if your interested. Do you have a >graphics >program. > > >Steve Marcum P.T. >------------------------------------------------------------------------ > >2X 2X 2X DOUBLE REWARDS POINTS! 2X 2X 2X >Open a new NextCard Internet Visa account with a >qualifying balance transfer and you'll earn DOUBLE >Rewards points. Earn free airline tickets in half the >time! Intro rates as low as 2.9% APR and NO annual fee! >Apply Online NOW! >http://ads./click/63/0/nextcard > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted October 20, 1998 Report Share Posted October 20, 1998 I would also like to see a copy. Thanks again for sharing! Dean Myers, MS, PT DeanM@... Re: Documentation Does anyone have a successful flowsheet or streamlined documentation tool that you are using in a SNF? We are looking at decreasing are documentation time under PPS. Thanks Randy Titony Executive Director, RehabSource Yes, I have worked out something if your interested. Do you have a graphics program. Steve Marcum P.T. ------------------------------------------------------------------------ 2X 2X 2X DOUBLE REWARDS POINTS! 2X 2X 2X Open a new NextCard Internet Visa account with a qualifying balance transfer and you'll earn DOUBLE Rewards points. Earn free airline tickets in half the time! Intro rates as low as 2.9% APR and NO annual fee! Apply Online NOW! http://ads./click/63/0/nextcard Quote Link to comment Share on other sites More sharing options...
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