Documentation for Physical Therapist

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
June 13th, 2017

Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:

• Paint a picture of the patient’s impairments and functional limitations requiring skilled intervention;
• Describe the prior functional level to assist in establishing the patient’s potential and prognosis;
• Describe the skilled nature of the therapy treatment provided;
• Justify that the type, frequency and duration of therapy is medically necessary for the individual patient’s condition;
• Clearly document both Timed Code Treatment Minutes and Total Treatment Time in order to justify the units billed;
• Identify each specific skilled intervention/modality provided to justify coding; 
• Provide outcome measures or results of other assessment tools or measurement instruments, as appropriate, to demonstrate the clinical progress being attained by the patient in regards to the patient’s identified functional limitations

Documentation may be submitted in any format as long as all the necessary information is captured.

References:

• LCD L34049