01 Therapy Assess/Plan

Purpose: 

To guide therapists on the use of the Assessment / Plan to guide strong clinical documentation and justification of skilled therapy services that are reasonable and necessary.

Question Intent: 

The Therapy Assessment / Plan section is intended to provide the interpretation of objective testing as well as the justification of why skilled therapy is reasonable and necessary for the patient at this time. It is important that these primary components are documented to support the patient’s need for skilled therapy services.  

Per Medicare Benefit Policy Manual Chapter 7 - Home Health Services, the Therapy Assessment / Plan portion of our notes helps support that "the skilled services must also be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury.  It is necessary to determine whether individual therapy services are skilled and whether, in view of the patient's overall condition, skilled management of the services provided is needed."  

Response – Specific Instructions: 

1. At SOC (00) and Evaluation (01) visits the Therapist will select Therapy Assess/Plan in their visit note. The system will ask if ‘ARE THERE FURTHER VISITS PLANNED AFTER EVALUATION TODAY?’. 
2. When “YES” is selected the Therapist will proceed as follows:
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   2. After selecting “YES”, a problem list will appear. Clinician to select problems identified from assessment and if not on list, the impairments can be placed under “Other” and typed in. These lists are discipline specific. The below list is for a Physical Therapist.
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   3. Next, the therapist will indicate the type of therapy they are providing. Clinician will select the type of therapy.
      1. For restorative care – expectation is patient improvement from lower level to higher level of function that is supported by functional tests/measures. 
      2. For maintenance care – expectation is patient sustaining function or reducing decline with strong justification as rational and skilled needed by a therapist. Functional tests/measures support sustainability from assessment to assessment and degree of impairment. 
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   4. When ‘Restorative’ is selected, two items will be addressed:
      1. Discuss what objective tests support the assessment. List out tests and why they are important. Below is an example:
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      2. Provide rationale, based on tests and other findings, why therapy is needed specific to this patient. Key here is to relate rationale to the specific patient circumstances:
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   5. When ‘Maintenance’ is selected, two items will be addressed:
      1. Discuss what objective tests support the assessment. Objective tests measure if the patient is sustaining functional level from assessment to assessment. Below is an example:
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      2. Provide rationale, based on tests and other findings, why therapy is needed for this specific patient. It is very important to be detailed to what is the risk to patient if therapy services are not provided:
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   6. Lastly, indicate the therapy plan. Use the drop-down list to create a list of interventions to perform. The Pathways chosen in the evaluation should align closely to your therapy plan. If items for your plan are not on the list use the “OTHER” option and free text any additions. Each plan is specific to a discipline. The below list is for a Physical Therapist.
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3. If “NO” is chosen for further visits planned, an indication for why no further therapy visits is required:
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   3. If ‘NO SKILLED THERAPY NEED IDENTIFIED’ is selected, a text box will open to provide the specific reason. Example below:
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   4. Lastly, the Therapy Plan will be selected:
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