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In a changing health care environment, physical therapists cannot afford third-party payer denial for medically necessary physical therapy services they provide. Common reasons for denials include:

• Technical errors such as:
  • identifier omission
  • incorrect form use
  • incorrect information
  • inadequate information

• Non-technical errors such as:
  • illegibility
  • good documentation in wrong place
  • bad documentation anyplace
  • billing information that does not match documentation of care
  • goals that do not match problems or diagnosis
  • outcomes or effectiveness of therapy services for patient's illness or injury (i.e., goals not achieved) are not documented
  • patient achieved their restorative potential and were provided repetitive, non-skilled exercises
  • patient did not require the care of a skilled therapist based on documentation
  • loss of function or functional limitation was not identified (problems were physiologically impairment based)
  • potential for significant improvement not identified (goals were not significant enough to justify care, or patient was too high level or too low level)
  • need for skilled therapist not identified (improvement would have been made without therapeutic intervention)
  • maintenance type therapies were being provided (rote, repetitive treatment to maintain same level of function)
  • lack of objective, measurable, or standardized evidence based tests and measures

Incorporating all of the general principles for documentation and health information management should help the therapist maintain records appropriately, organize the record, record appropriate information, and justify and receive reimbursement based on the documentation content. The therapist should seek to write only what is relevant and necessary in an objective manner, using verbiage that indicates skill, but is universally understood based on all purposes of the medical record. By appreciating why payment for skilled physical therapy services is denied, the therapist can reflect on documentation content guidelines and the importance of content adherence.

This textbook will help lay the foundation on What, How, and Why to document. Legal issues, coding, utilization review, and utilization management are just a few of the content areas covered.

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