I have written extensively about the technical requirements for Medicare Compliance, and I recently had the pleasure of co-presenting a webinar with Nancy Beckley called Medicare Made Simple. I think the webinar gave a good, high level introduction about technical Medicare Requirements, and I hope that you find it useful.
Defensible Documentation
I would like to step away from the technical requirements a bit in this article, and offer some basic advice on creating Defensible Documentation. These principles certainly apply to Medicare, but I think they apply equally to all payers, and they can be boiled down into one sentence:
Your documentation should tell a concise, understandable story about your patient’s functional limitation and a logical, acceptable plan for achieving a realistic functional goal in a reasonable amount of time.
That’s it! Of course, this is all much easier said than done. You may well have a different opinion on how your documentation stands up to the “understandable, logical, reasonable, acceptable, realistic” requirements than a RAC auditor, so no one can guarantee success in an audit. But I can guarantee failure if you make no effort to tell a story that meets these requirements. Let’s break this down a bit:
- “Concise”: Use the minimum number of words necessary to tell the story.
- An “understandable story” is just that. Describing the functional limitation of your patient, the important clinical findings that show evidence of the functional limitation and communicating why it is important is the linchpin of success here. Pretend like the person reading your report has no technical knowledge. Describe the functional limitation in layman’s terms. Make a compelling case that the functional limitation makes sense based on your clinical findings. It is simply a description of the Big Problem.
- A “logical, acceptable plan” means that the plan has to make some sense and meet requirements of being a medically acceptable intervention. Is your plan Evidence Based?
- A “realistic” functional goal. Can you convince the person reading your report why the goal is realistic? This is where the prior level of function comes into play, and is one of the pieces of evidence you can use to build a case for a realistic goal. (This brings to mind the old joke about the patient who says to his hand surgeon “Will I be able to play the violin after the operation?” The hand surgeon answers “Of course”. The patient says “Great, I never could before!”)
- The “reasonable amount of time” is also open to interpretation. I can say with confidence that it is less than forever, and that at a minimum, you have to communicate that there is an end in sight.
Watch our ‘Day in the Life of a Therapist’ video to see how it works.
