Documentation
Efficiency
Efficiency
When is the MOST optimal time to generate an Initial Evaluation OR a Daily Note?
BEFORE the patient arrives (depending on your work flow)
1.IEs-At the the beginning of the day or a few hours
2. Daily- A few minutes
In the Initial Evaluation, where can I find this information in support of the goals?
1. Current History
2. Current Complaints
3. PLOF and CLOF-BE Specific!!!
How many charges should a therapist charge in a session if you are a STRONG performer?
Neuro Mixed Ortho
Neuro Mixed Ortho
Charges 4.0 4.2 4.3
Procedures 3.8 4.0 4.0
What (3) places can you find the insurance guidelines
1. Web PT Alerts
2. Chart Notes
3. Payor Reference Sheet
Who is your rehab team?
Yourself
Fellow PT/PTA/OT/OTA/SLP
Clinical Assistants
Administrative Assistants
Housekeeping, Janitor, any other support staff
In reference to being EFFICIENT...What are the 5 P's?
Prior
Planning
Prepares (you)
Perfect
Performance
What Acronym do we use for our goal creation AND what do they stand for?
S-specific
M-measurable
A-attainable
R-realistic
T-time Based
How many procedures should therapist complete in a session if you are a STRONG Performer?
Neuro Mixed Ortho
Neuro Mixed Ortho
Procedures 3.8 4.0 4.0
When do you generate a Medicare Utilization Review? an Aetna review? A high Visit count?
Utilization Review- $ 2000
Aetna-@0 visits
High Visit- 20 visits
When do you introduce your rehab team?
At IE and subsequent visits (TALK them UP!)
When a new team member comes on board
When patient transfers to another site
When referring to other specialties
How many ICD-10 codes should you optimally use and WHY?
3
Strengthens your justification for care
Should Short Term and Long Term goals be related? Give an example...
YES! Long Term goals BUILD on short term goals!
IE-Reach into lowest cabinet shelf vs top shelf in order to do SOMETHING functional
If a therapist has to step in a private room can they charge GROUP? What are the FOUR aspects of GROUP?
No! Ther therpist MUST be in constant attendance
Simultaneous but not continuous
same or different exercises
Therapist in constant attendance
No one on one contact required
When do you have to use a GROUP Statement? what is the statement?
UHC-Some plans
Location: In Clinic Number of Clients in group: 2 Activity and Purpose: See flowsheet in eDOC; Exercises completed in order to: Increase Range/Strength Stability/Balance Functional Mobility of
Why is it important to introduce your rehab team to you patient?
Set Expectations
Instill confidence between patient & team
Generate trust in the team
ensure EXCELLENT Customer Care
When should you generate a POC?
IE- Medicare, Medicaid, SOME UHC, Prescription variations
Re Eval-Medicare- End of POC (90 days)
Re Eval All-Change of POC (add body part etc), updated visits beyond referral
When do you update goals?
1.Progress Summary/Re evaluation
2.Re certification
3. Physical Performance Test
4.Discharge
5.Daily notes?
If your WC patient is returning to work and you have to assess lifting, what would you charge? Why?
Physical Performance Test
Need for multi-varied tests for a planned purpose.
When do you have to add rationale for the justification of charges?
When you start or change the exercises
BASED on INTENT
Can a Clinical Assistant turn on an Estim or Game Ready machine if I am hands with a patient?
No!
What areas should you use SMART Text?
Current History
Current complaint
Assessment
Education
Goals
HOW do you update or modify goals?
1. Update CLOF
2. Update Goals
-Write in the % achieved
-Write in Text box rationale
3.Modifiying goals
What reports do you or your leader run regularly to let you know how you and hour clinic are performing?
Productivity-Charges
LERS-Diversification
No Show/ Cancellation report
Google Review-Posted online
NPS Scores-Feedback by text/emaiul
A document has Time IN and Time Out. What Insurance is this?
UHC
Can you charge for exercises that a Clinical Assistant introduces to a patient?
NO! Cas do not have the qualification to introduce exercise. they CAN be our eyes are ears though!
CAs are patient care extensions and are under the therapists supervision