With recent changes in payment and reimbursement (and more to come) and the influx of common software, many clinicians are focused on the volume of documentation versus value. Not only is this inefficient, it contradicts what payers require. This session will explore how CMS and payer sources review records, giving you insight into how to focus your documentation. Attendees will learn the 5 platforms of successful documentation, which ensure every requirement is met while allowing you to document your skill for each client using clinical reasoning. Actual case studies and intervention examples will be completed ensuring immediate carryover into your clinical setting.
- Identify how payers review documentation, who reviews documentation, and the general process of review.
- Outline the three documentation areas most commonly reviewed including good and bad examples in all three areas.
- Critique the five platforms required for successful documentation and how the platforms address the commonly reviewed areas.
- Complete actual documentation examples with common therapeutic interventions utilizing the platforms.
Why Reviews Happen
- Purpose of RAC and documentation review
- General process of review
- Identify red flags
- Rends (OP- Medicare B, In-patient – Medicare A, HH)
Most Commonly Reviewed
- Top three areas
- Qualified clinician
- Skilled level of care
- Medical necessity
- Appeals process: what to do if a review is requested
- Requirements of a “maintenance program”
Five Platforms of Successful Documentation
- Underutilized terminology
- Trap phrases to avoid
- Address commonly reviewed areas
- Case studies:
- Joint mob
- Gait ther-ex
- Transfer training
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