Documentation and reimbursement of home physical therapy services

Abstract

Documentation has long been the basis for reimbursement decisions by third party payers. Al though reimbursement is not the sole or primary reason for good documentation, it has an influ ence on what physical therapists document. Key documentation components need to be ad dressed to insure that Medicare requirements for home physical therapy services are met. Traditional documentation often lacks sufficient reference to functional status and skilled needs of the patient, and such deficient documentation provokes denial of the claim. Physical therapy claims are selected for Medicare review based on numerous factors, such as diagnosis, number of visits or duration of care. However, the claims are judged on the basis of submitted documentation. With the implementation of non-traditional methods of documentation, such as focus charting and charting by exception, the key elements of documentation must still be evi dent to the reviewer. Regardless of payer source or charting method, complete, thorough and accurate documentation that reflects skilled services related to functional tasks is the best route to approval of claims.