Documentation is the means of communicating information from the treating professional to all users of the medical record. It is the “what” therapists do and “how” it is performed. It is imperative to clearly and concisely communicate only the information that is relevant and necessary about care provided and the resulting condition of the patient or client.
As defined by the American Physical Therapy Association (APTA), “Utilization review (UR) is a system for reviewing the medical necessity, appropriateness and reasonableness of services proposed or provided to a patient or group of patients. This review is conducted on a prospective, concurrent and or retrospective basis to reduce the incidence of unnecessary and or inappropriate provision of services. UR is a process that has two primary purposes: to improve the quality of service (patient outcomes) and to ensure the efficient expenditure of money.”1 It also serves to:
- Ensure delivery of cost-effective high-quality physical therapy services
- Identify inappropriate or less effective and less efficient services with corrective action
- Assure of compliance with accreditation and licensing guidelines
- Ensure the continuum of care in a timely manner
- Assure that medically necessary care was delivered
- Facilitate avoidance of unnecessary care beyond goals, beyond point of progress
- Determine if delivery of service not indicated in plan
- Determine if service not rendered for problems identified
- Discover if no baseline level of care provision based on information provided
- Ensure referral(s) to other practitioners when out of the therapist's scope of “expertise” by training, experience, or otherwise
- Facilitate risk management (prevention of all types of loss)
- Identify the appropriate physical therapy personnel provided care for level of skill required or by virtue of third party payer requirements
Prospective review, a component of UR, may also be referred to as utilization management (UM). UM is based on the information derived from the review process both internal and external to the organization providing services, to ensure quality of service and effective and efficient delivery.
UR is considered a component of quality assurance and may be referred to as utilization review and quality assurance (URQA). In organizations or facilities with ongoing quality improvement or quality assurance programs and monitoring, URQA is often used.
Before 1965, UR was largely experimental and not performed by many providers. Medicare introduced a new era in accountability with a requirement for all hospitals participating in Medicare and Medicaid programs to forming UR committees and develop written UR plans. Initially the programs were not successful because the focus was on the fiscal portion of care, the interpretations were inconsistent, and coordination of benefits was often nonexistent. In 1972, professional standards review organizations (PSROs) primarily for physician services were initiated. PSROs employed nonphysicians and physicians to review the appropriateness and quality of medical services. Although nonphysicians performed the initial review and could affirm care, only a physician could deny services. Little was done with rehabilitation review however, the focus instead being ...