I agree with Arley. Denials come more often from the inability to document skilled intervention, than from poor goal writing. I frequently see documentation from therapists such as: Ambulated 75' with min (A) or; completed upper body dressing with mod (A). This is not skilled intervention. An aide can do that. The key is to write what you did that facilitated there ability. An example is utilized reflex inhibiting positioning for tone reduction to allow the patient to don there socks with min (A) for initial application over the toes. Another thing I see often is the documentation of long lists of exercises. Beyond the argument for or against exercise, a list of exercises performed is not skilled. You can go to your local gym and a handy dandy employee of the gym can help you do a long list of exercises. Again, the therapist needs to state what they did that was skilled. an example: Note the exercises you had the patient perform and state what type of cueing was required to limit substitution patterns. Beyond the above, I do not know of a documentation course. It is a good idea to find out what the regulations say in terms of documentation. Transmittal 60, which can be found at the CMS website lists documentation requirements for part B treatments. There is not much available for Part A, however, recently Medicare attempted to make Part B documentation regulations as a rule for Part A. This was later rescinded, but I'm sure it will turn up again sometime. I also agree that being detailed in notes is a good thing. I'm not certain I have ever heard of a Medicare contractor denying a claim as it was too long to read, but if it were denied, I would love to have detailed documentation to help me fight the denial at a hearing. Just make sure you are documenting the salient details only. I've observed many to write a lot without saying much. As for your goal example, I would say that the bit about "skilled dressing technique" is somewhat confusing. What do you mean by "skilled." It may be more appropriate to list specifically what you are training. An example: The patient will display 100% return demonstration of ability to safely transport items of clothing from closet/drawers while using a rolling walker. In the long run, if your supervisor keeps telling you that detailed notes will get you denied, ask him to provide his resource for this information. He will not be able to as there is none. Jim
Jet & Jen Ramos <[EMAIL PROTECTED]> wrote: thank you for the feedback...you actually made it to the point. the reason why i am detailed (wordy) was due to the "other" conditions that needs to be met/addressed - Common example of a Goal for a Pt that may also have Balance impairment in standing (LE weakness could be a G example too): Pt to achieve SBA in UE dressing. In the real world, Pt. may be able to do it min A within "X' number of Tx. sessions BUT what needs to be addressed, as well, would be giving skilled instructions on safety techniques, strategies and sequencing in dressing to achieve good carryover since Pt usually do it (prior to ilness/disability) in standing position and skilled dressing techniques need to be carried over while sitted on min A to make more sense. My rant is: I may wrote the goal like this: Pt to achive SBA in UE dressing with G carry over of skilled dressing techniques and strategies in sitted position to increase/compliment safety. Accdg to my PT director and supervisor, it's not necessary, too long and it's not up to the point ... what's more intriguing is, Auditor/Medicare may not read it since it's long and denial of payment is apparent......honestly, I think, more often than not, therapist are used to cookie cutter LTGs and STGs and the real essence of the targeting the problem is not addressed. Safety may show up on progress notes and that skilled instrxns or Pt. education were addressed but the way i worte my goal would account for both - so, even Pt. achieved Min A goal, it's not over yet until carryover of skilled techniques and strategies are met. MY POINT ? - which goal is better now? Come to think of it, one of the reasons why we are training dressing skills might be to sustain task to promote max. independence and put "safety" in equation because I believe Pt. (an ADULT without cognitive impairment) knows the concept and has the experience on how to do the task per se but because of limitations secondary to trauma, disease or illness, it is compromised. FAVOR, do you (or anyone) know a GOOD training/seminar regarding OT documentations that would improve Medicare reimbursement and avoid denials? I would like to know if there's really something wrong with how I document my Txs. Thanks. "Johnson, Arley" wrote: The Ramoses: Being detailed is what gets you reimbursed. A course I went to that discussed Medicare Denials PT/OT notes that were "status reports" ( Min A LE dressing, Min A Sit to Stand, etc..)could be done by anyone and that our notes need to state why skilled intervention was needed (Min A LE dressing with VCs to maintain balance and attention to task. I'll pass on the notes later when I get back to work. Arley Johnson, MS, OTR/L Operations Manager Rehabilitation Services Pennsylvania Hospital, the Nation's First Basement, West Wing 800 Spruce Street Philadlephia, PA 19107-6192 215-829-5018 - office 215-422-0174 - pager ________________________________ From: [EMAIL PROTECTED] on behalf of [EMAIL PROTECTED] Sent: Sat 9/1/2007 9:51 PM To: [email protected] Subject: Re: [OTlist] Documentation hi, i would like to have the outline as well since i was being told that my documentation, although detailed, might not be a good way to do it and medicare might deny payments since its detailed...twas accdg to my "P.T." supervisor. No one could give me a good OT documentations and honestly, mine is better. thanks in advance. -- The Ramoses ---- Jenny Daup wrote: > Sheila, did you take AOTA's course? I took one earlier this year online and > I thought it was pretty good. I made a little outline of the important > points that I got out of it because I was designing forms for a new practice > and it came in handy. > I'd try to find my little outline for you if you want to e-mail me. > Jenny Daup > [EMAIL PROTECTED] > > > -----Original Message----- > From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf > Of Sheila Wilson > Sent: Friday, August 31, 2007 2:18 PM > To: [email protected] > Subject: [OTlist] Documentation > > Does anyone out there know of a course on documentation? I have been > trying to find one for OT on documentation for reimbursement and for > meeting Medicare guidelines. The AOTA has been of no help in this > search and I've run out of ideas! > > Thanks - > Sheila > -- > Options? > www.otnow.com/mailman/options/otlist_otnow.com > > Archive? > www.mail-archive.com/[email protected] > > **************************************************************************** > ********** > Enroll in Boston University's post-professional Master of Science for OTs > Online. Gain the skills and credentials to propel your career. > www.otdegree.com/otn > **************************************************************************** > ********** > > -- > Options? > www.otnow.com/mailman/options/otlist_otnow.com > > Archive? > www.mail-archive.com/[email protected] > > ************************************************************************************** > Enroll in Boston University's post-professional Master of Science for OTs > Online. 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