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:
- At Routine (11) visits each visit should indicate how the patient is progressing towards their goals. This documentation speaks to incremental gains from visit to visit or week to week as compared to a formal reassessment whish is longer in length and more thorough of the entire plan of care. Keep responses to routine visits concise and relevant to the goals written.
- In the first question, Indicate how your patient did on the visit today in an objective format. The below example if for a PT patient:
- In the second question, discuss of the patient responded to your interventions performed. Were there any physiological changes/responses, learning responses, skills gained, physical responses, teach back level, etc. Speak to if they responded to the session in a positive or negative manner and if negative, why do you think that is. Be concise and specific to the patient. Avoid using only improve and or function alone, but add specifics. The below is example is for a patient receiving PT:
- Lastly, indicate the continued therapy plan. Select from the drop downs the items that you plan to complete next session. The lists are discipline specific and the below example is for a PT.
