Webinars & Audio Conf

The Lost Art of Writing: Documenting Medical Necessity

Date:  Tuesday, September 26, 2017

Time:  2:30pm EST / 11:30am PST (length is 1.5 hours)

Description:

The “writing is on the wall.” Every day we see published reports of multiple rehab settlements; CMS reports on overutilization of therapy minutes and lack of documentation to support the intensity of therapy provided; increased recovery audit activities; and more.

While there are many advantages associated with the migration toward complete electronic healthcare documentation, the art of writing quality notes has been lost amidst drop down boxes and build-a-sentence functions. When you need to capture attention, using similes, metaphors, and vivid imagery to paint a picture, it creates a powerful emotional response.  The same should hold true when therapists document medical necessity. The therapist’s documentation need to describe services and outcomes for each individual resident clearly. Most therapists have not developed the skills to document clinical reasoning sufficiently to meet the stringent medical necessity requirements by Medicare and other third-party payers.

The changing environment means that therapists need not only to be knowledgeable in the latest techniques or modalities but they also need to document meticulously what they do and why they are doing it. Therapy documentation must reflect skilled therapy interventions to manage specific deficits. Effective documentation begins with a solid understanding of the requirements outlined in the Medicare Benefit Policy, Claims Processing, and Program Integrity Manuals. Keeping current with the latest compliance directives is no longer an option but a professional obligation.

Staff members think they have master the art of writing a thorough evaluation, progress note or discharge summary, it’s time to test competency through a self-audit. Does your organization’s documentation effectively convey medical necessity and skilled care? High-quality documentation serves the organization well because it provides a real-time, historical account of therapy encounters with residents. Thorough and accurate documentation can be an important source of evidence in the event claims are reviewed for payment or quality of service concerns.

Learning Objectives:

• Understand the Recovery Audit Program/Manual Medical Review Process and its impact to documentation of medical necessity
• Increase awareness of current clinical documentation issues that may result in denial of payment
• Describe and implement the necessary components of documentation to support medical necessity
• Utilize tools and resources to conduct a self-audit

Cost:

NARA Member:  $149 per registration  (Elite Members: Free)

Non-NARA Member:  $299 per registration

Speaker:

Angele Tran, OTR/L, CAPS.  With over 25 years of operational and clinical experience in healthcare, Angele functions as a compliance specialist for Friends Services for the Aging who provides compliance and risk management services to non-profit communities. Angele brings a background with a focus in long-term care and experience in acute and sub-acute rehabilitation. She has presented at AOTA, Leading Age PA and MD and American Burn Association.

Her expertise includes therapy staff development; documentation compliance; management training and monitoring; development of pathways, protocols, policies and procedures for therapy; therapy program enhancement; Additional Development Request and denial management; development of performance improvement and clinical compliance programs; and Medicare regulations and resources. She has also assisted with selection and implementation of an Electronic Health Record.

CEUs:

PT/PTA/OT/COTA:  1.50 Contact Hour /0.15 CEU

Must register individually, be active during presentation and complete assessment