Guest guest Posted February 22, 2006 Report Share Posted February 22, 2006 Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg concerning therapy documenation. I have therapists that are completing evals in the following manner: Establishing a prior level of function Not testing areas of mobility, but establishing an intervention and goal. Pruitt Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 22, 2006 Report Share Posted February 22, 2006 , Sounds like a great opportunity for medicare to deny. How can they show progress without establishing a baseline starting point? They need to be educated to do so, or get to participate in your disciplinary program. Just my 2 cents. Mcloughlin Cushing Memorial Hospital PT, OT, SLP evaluation Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg concerning therapy documenation. I have therapists that are completing evals in the following manner: Establishing a prior level of function Not testing areas of mobility, but establishing an intervention and goal. Pruitt Please identify yourself, your discipline and your location in all posts to PTManager Looking to start and own 100% of your own Practice? Visit www.InHomeRehab.com. PTManager encourages participation in your professional association. Join and participate now! Please identify yourself in all postings to PTManager. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 22, 2006 Report Share Posted February 22, 2006 CMS PUB. 100-02 Chapter 15 defines an evaluation as a separately payable comprehensive service that requires professional skills to make clinical judgements about conditions for which services are indicated BASED ON OBJECTIVE MEASUREMENTS and subjective evaluations of patient performance and functional abilities. McNeal PT, OT, SLP evaluation Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg concerning therapy documenation. I have therapists that are completing evals in the following manner: Establishing a prior level of function Not testing areas of mobility, but establishing an intervention and goal. Pruitt Please identify yourself, your discipline and your location in all posts to PTManager Looking to start and own 100% of your own Practice? Visit www.InHomeRehab.com. PTManager encourages participation in your professional association. Join and participate now! Please identify yourself in all postings to PTManager. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 22, 2006 Report Share Posted February 22, 2006 ; There are numerous sources and references related to documentation, from the professional associations, Medicare, and the State. From the Medicare perspective, you would need to specify what type of claim you are looking to support. Of course the professional and legal standards cross all practice settings. I suspect, however, that your problem is bigger than a simple lack of references. Perhaps your therapists need a " crash course " in what it means to be a professional, with all that it entails. You are not alone in this by the way, as we have spoken and worked with other practices and facilities with the same problem. Sincerely, Ken Mailly, PT Mailly & Inglett Consulting, LLC Tel. 973 692-0033 Fax 973 633-9557 68 Seneca Trail Wayne, NJ, 07470 www.NJPTAid.biz Bridging the Gap! Confidentiality Note: This electronic mail is a communication from M & I Consulting that may be privileged, confidential or otherwise protected from disclosure. This information contained herein, is intended to be for the addressee only. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled. If you are not the addressee, any disclosure, copy, distribution or action taken in reliance on the contents of this electronic mail is strictly prohibited. If you have received this electronic mail in error, please notify the sender immediately. > PT, OT, SLP evaluation > > Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg > concerning therapy documenation. I have therapists that are completing > evals in the following manner: > Establishing a prior level of function > Not testing areas of mobility, but establishing an intervention and goal. > > Pruitt > > > > > > > Please identify yourself, your discipline and your location in all posts > to PTManager > > Looking to start and own 100% of your own Practice? > Visit www.InHomeRehab.com. > PTManager encourages participation in your professional association. Join > and participate now! > > Please identify yourself in all postings to PTManager. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 22, 2006 Report Share Posted February 22, 2006 If you want a description of what Medicare requires for documentation of therapy services, I would refer you to Transmittal 46 that was issued by CMS a couple of weeks ago. It includes a new section 220.3.5 for Publication 100-02, chapter 15, that is devoted entirely to the subject. For professional standards on appropriate documentation, one reference would be the APTA guideline: Physical Therapy Documentation of Patient/Client Management, which is available free to members on the APTA web site within the Board of Directors policies and positions (BOD 03-05-16-41) or can be purchased by others. I don't know if AOTA or ASHA have similar documents, but I presume that they do. Ken Tuley, PT, MSHS Director, Rehab Services Health First, Inc. Brevard County, FL >>> ppruitt@... 02/22/2006 2:09:19 PM >>> Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg concerning therapy documenation. I have therapists that are completing evals in the following manner: Establishing a prior level of function Not testing areas of mobility, but establishing an intervention and goal. Pruitt Please identify yourself, your discipline and your location in all posts to PTManager Looking to start and own 100% of your own Practice? Visit www.InHomeRehab.com. PTManager encourages participation in your professional association. Join and participate now! Please identify yourself in all postings to PTManager. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 22, 2006 Report Share Posted February 22, 2006 The APTA website has online courses on documentation. The rule of thumb we use is, never write a goal that doesn't match,address a specific problem. PT, OT, SLP evaluation Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg concerning therapy documenation. I have therapists that are completing evals in the following manner: Establishing a prior level of function Not testing areas of mobility, but establishing an intervention and goal. Pruitt Please identify yourself, your discipline and your location in all posts to PTManager Looking to start and own 100% of your own Practice? Visit www.InHomeRehab.com. PTManager encourages participation in your professional association. Join and participate now! Please identify yourself in all postings to PTManager. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 22, 2006 Report Share Posted February 22, 2006 You may want to check your LMRP as ours is pretty details as to the documentation requirements for Medicare Reimbursement. Hope this helps Jill Piazza, PT, MSPT Florida Hospital DeLand PT, OT, SLP evaluation > Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg > concerning therapy documenation. I have therapists that are completing > evals in the following manner: > Establishing a prior level of function > Not testing areas of mobility, but establishing an intervention and goal. > > Pruitt > > > > > > > Please identify yourself, your discipline and your location in all posts > to PTManager > > Looking to start and own 100% of your own Practice? > Visit www.InHomeRehab.com. > PTManager encourages participation in your professional association. Join > and participate now! > > Please identify yourself in all postings to PTManager. > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 23, 2006 Report Share Posted February 23, 2006 You might want to check the FI web site that is primary in your area. I have seen several FI's put identical info on their site... so I suspect they borrow and pass it on. Look for a document on PT Local Coverage or Rehab Local Coverage that is usually found when you go to the Part B side of the site. First Coast in Florida is easy to search; so, I am quoting them on what they expect in an evaluation. (see insert after the ****) Also, I got a huge dose of reality shock the first time I had to defend a case in front of a Judge. While I don’t recommend you send people to fight your denials or defend court cases... it might be fun to do a " mock court case " and have a therapist defend their treatment and billing. Remember, you are defending against someone who knows their business... and if its not documented.... opps. **** Evaluations must contain the following information. This information may be found in the evaluation and/or the Plan of Treatment: • Reason for evaluation • Diagnosis/condition being treated and its date of onset • Past level of functioning, be specific • Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring progress • Current level of function, using illustrations (e.g., cannot comb hair, cannot grip) • Measurements such as strength, ROM, pain level • Treatment modalities selected for treating current illness or injury • Limitations which may influence the length of treatment • Short and long term measurable goals and their expected date of accomplishment • Frequency and duration of therapy Steve Passmore PT Healthy Recruiting Tools spass@... PT, OT, SLP evaluation Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg concerning therapy documenation. I have therapists that are completing evals in the following manner: Establishing a prior level of function Not testing areas of mobility, but establishing an intervention and goal. Pruitt Please identify yourself, your discipline and your location in all posts to PTManager Looking to start and own 100% of your own Practice? Visit www.InHomeRehab.com. PTManager encourages participation in your professional association. Join and participate now! Please identify yourself in all postings to PTManager. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 24, 2006 Report Share Posted February 24, 2006 Dependent on your FI too- Ours (United Govt Services) has a Therapy Educational Guide on their website. Helped me to show my staff that I was not just being particular about documentation! The link is: http://www.ugsmedicare.com/provider_education/manuals/documents/Mar2005_Therapy_\ Guide.pdf Hope this helps! Beth Linville, M.A., CCC-SLP Director, Carilion Rehabilitation CMC/CNRV Roanoke, VA > >Reply-To: PTManager >To: <PTManager > >Subject: Re: PT, OT, SLP evaluation >Date: Wed, 22 Feb 2006 20:37:49 -0500 > >You may want to check your LMRP as ours is pretty details as to the >documentation requirements for Medicare Reimbursement. >Hope this helps >Jill Piazza, PT, MSPT >Florida Hospital DeLand > > PT, OT, SLP evaluation > > > > Can anyone direct me to a medicare reg or APTA, AOTA, or ASHA reg > > concerning therapy documenation. I have therapists that are completing > > evals in the following manner: > > Establishing a prior level of function > > Not testing areas of mobility, but establishing an intervention and >goal. > > > > Pruitt > > > > > > > > > > > > > > Please identify yourself, your discipline and your location in all posts > > to PTManager > > > > Looking to start and own 100% of your own Practice? > > Visit www.InHomeRehab.com. > > PTManager encourages participation in your professional association. >Join > > and participate now! > > > > Please identify yourself in all postings to PTManager. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 24, 2006 Report Share Posted February 24, 2006 I would recommend your read CMS Transmittal 47 that was released on 02/15/2006 regarding evaluation documentation, especially now to know the requirements with Progress Reports and Treatment Encounter Notes. http://www.cms.hhs.gov/transmittals/downloads/R47BP.pdf Rick Gawenda, PT Director PM & R Detroit Receiving Hospital > You might want to check the FI web site that is > primary in your area. I > have seen several FI's put identical info on their > site... so I suspect they > borrow and pass it on. Look for a document on PT > Local Coverage or Rehab > Local Coverage that is usually found when you go to > the Part B side of the > site. > > First Coast in Florida is easy to search; so, I am > quoting them on what they > expect in an evaluation. (see insert after the ****) > > Also, I got a huge dose of reality shock the first > time I had to defend a > case in front of a Judge. While I don’t recommend > you send people to fight > your denials or defend court cases... it might be > fun to do a " mock court > case " and have a therapist defend their treatment > and billing. Remember, > you are defending against someone who knows their > business... and if its not > documented.... opps. > > > **** > Evaluations must contain the following information. > This information may be > found in the evaluation and/or the Plan of > Treatment: > > • Reason for evaluation > > • Diagnosis/condition being treated and its date of > onset > > • Past level of functioning, be specific > > • Evaluations must contain physical and cognitive > baseline data necessary > for assessing rehabilitation potential and measuring > progress > > • Current level of function, using illustrations > (e.g., cannot comb hair, > cannot grip) > > • Measurements such as strength, ROM, pain level > > • Treatment modalities selected for treating current > illness or injury > > • Limitations which may influence the length of > treatment > > • Short and long term measurable goals and their > expected date of > accomplishment > > • Frequency and duration of therapy > > Steve Passmore PT > Healthy Recruiting Tools > spass@... > > PT, OT, SLP evaluation > > Can anyone direct me to a medicare reg or APTA, > AOTA, or ASHA reg concerning > therapy documenation. I have therapists that are > completing evals in the > following manner: > Establishing a prior level of function > Not testing areas of mobility, but establishing an > intervention and goal. > > Pruitt > > > > > > > Please identify yourself, your discipline and your > location in all posts to > PTManager > > Looking to start and own 100% of your own Practice? > > Visit www.InHomeRehab.com. > PTManager encourages participation in your > professional association. Join > and participate now! > > Please identify yourself in all postings to > PTManager. > Quote Link to comment Share on other sites More sharing options...
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