Avoid Common Rehabilitation Documentation Errors!

By Margaret Schmidt tags:

Shelly Mesure, owner of national rehabilitation management consultancy “A Mesured Solution, Inc.,” recently identified ten common errors in rehab documentation that can delay payment for therapy services. In her “Rehab Realities” column for McKnight’s Long-Term Care News, Mesure suggested that in order to avoid denials and see claims through to reimbursement, therapists must watch out for the following mistakes:

  • Failure to sufficiently indicate medical necessity
  • Missing signatures from physicians for supervisory visits, etc.
  • Using unsupported ICD-9 codes and other coding errors, such as improper use of modifiers
  • Duplication or computerized cloning when describing services administered

Click here to read the rest of Mesure’s recommendations. And remember, as stated in RehabCare’s white paper, “The Importance of Clinical Outcomes in Rehab Programs,” the best documentation strategy is based on a three-tiered approach:

  1. Level of function before rehab
  2. Status of functional improvement at first evaluation
  3. Status of functional improvement at discharge

Quality documentation and understanding the claims process from start to finish is critical to withstand the scrutiny of claims audits. Please share your best practices for documentation. What would you add to Mesure’s list?