Developing, reassessing, and documenting toward therapy goals and current function are essential building blocks toward a necessary and comprehensive therapy care plan. All visits performed for therapy are subject to scrutiny based on medical necessity which is entirely determined by the documentation provided by the therapist. In order to exhibit evidence of a successful home health therapy mission, there are three key areas of focus:
- The documentation upon initial evaluation and the development of reasonable, necessary, and specific goals tailored to the patient’s functional status
- The ongoing documentation toward the patient’s progression toward initial goals in each subsequent therapy visit
- The comparative documentation of original goals with current status on the 30-day functional reassessment
Initial Therapy Evaluation and Goals
It is imperative upon evaluation to clearly document all areas which affect the patient’s functional status in order to develop a comprehensive and reasonable plan of care. The following should be documented:
- Reason for referral
- The diagnosis or condition to be treated
- Past and current level of function
- Baseline physical and cognitive status evaluation
- Current objective measurements for ROM, level of assistance, use of specific assistive devices, strength measurement, distance, TUG, Tinetti, etc. and any other contributing factors that may influence treatments
- Treatments pertinent to the current diagnosis, illness, or injury
- Patient/caregiver goals for this episode of care
The goals (as applicable) should be specific and measurable to include the following, as well as duration of short- and long-term goals so that throughout the certification period, progress can be clearly determined from each visit. Examples include:
- Data on admission of current state of ROM and the goal to be attained
- Data on admission of current state of strength (i.e., 2+/5) and the goal to be attained
- Data on admission of current balance score using method chosen by the agency and the goal to be attained
- The specific type of assistive device currently used and the goal for the assistive device to be used for ambulation, transfers, and stairs (Wheelchair, RW, 4WW, cane, etc.)
- The type of assistance needed (Max, Mod, Min, CGA, SBA, Mod I, I) for bed mobility, transfers, ambulation (if able, specify for even/uneven ground and indoor/outdoor ambulation), stairs on admission, and the goals to be attained
- Data on admission of current state of balance and safety (TUG, Tinetti scores) and the goal to be attained
- Any other pertinent goals specific to the patient’s ability to remain safely in the home or be able to leave the home safely
When therapists document specific and measurable goals properly, the need for therapy and progress towards those goals is evident. The following are essential components of therapy documentation for each encounter that apply to the overall picture of the patient’s physical progression from visit to visit:
- A physical exam pertinent to the day’s visit and any relevant history, including the patient’s response or any changes since the previous visit
- Skilled therapy performed on the current visit
- The patient/caregiver’s response to the skilled service provided
- Objective measurements of physical ability based on the treatment provided
- Documentation toward goals achieved regarding ROM, level of assistance, use of specific assistive devices, strength measurement, distance, TUG, Tinetti, etc.
- A detailed explanation supporting the necessity for further therapy services based on the outcomes of the visit and the progress thus far
- Any other documentation necessary that details the necessity for home health therapy services including homebound status
It is also important to focus on documenting what the patient is specifically capable of such as, “the patient is able to perform a safe transfer from bed to commode with SBA and use of FWW”. Avoid using general statements such as, “the patient is doing well” or “the patient’s mobility is improving”.
30-Day Functional Reassessment Documentation
At least once every 30 days, each therapy discipline involved in the plan of care for a patient needs to perform and document a functional reassessment. A qualified and licensed therapist, not an assistant, must perform this reassessment. In addition to the components of the initial evaluation, a comprehensive evaluation should be utilized to documents any adaptation of goals or provide support for the continuation of services. The following additions can help support medical necessity:
- Data obtained from the previous evaluation regarding objective measurements for ROM, level of assistance, use of specific assistive devices, strength measurement, distance, TUG, Tinetti, etc.
- Data obtained from the current day evaluation regarding objective measurements for ROM, level of assistance, use of specific assistive devices, strength measurement, distance, TUG, Tinetti, etc.
- Any new information that may assist in determining the need for continued therapy, a change in goals based on the ability or inability to attain them (i.e., a patient had an injury and was previously medically prescribed as NWB and is now FWB), or a need for discontinuation of services (i.e. a patient that has been referred to outpatient therapy or perhaps the patient has moved out of the agencies service area)
- Any other physiological or cognitive change in condition that may affect the overall outcome for this patient
Although therapy is no longer a financial driver under PDGM, as it was under PPS, a comprehensive therapy functional reassessment decreases the risk of payment reduction for period 2 under PDGM. Inadequate therapy reassessment documentation may result in period 2 dropping to a LUPA or a full payment denial for period 2. The need for comprehensive and detailed information that clearly demonstrate progress from the initial evaluation to the completion of necessary therapy goals is a key factor in successful therapy episodes.