Links and some documentation examples to understand what is required for billing. Most commercial insurance follows these basic requirements but are not as restricted on “timed” codes.
Examples of Goals related to Lymphedema ( include this as link to a PDF within site) covering the patients overall needs:
- ability to pull on and remove garments
- skin status such as hyperkeratosis, papillomatosis, wounds, moisture level (weeping or excessively dry) what soaps or cleansers have been used.
- safe functional mobility, balance with and without compression in place, assistive devices
- cognitive or visual functional goals if applicable (example: pt. will be able to visualize wound at back of leg, will be able to make proper judgments re: ongoing self-management, the ability for new learning or need for supervision)
- range of motion including limitations
OUTPATIENT REHABILITATION THERAPY SERVICES:
COMPLYING WITH DOCUMENTATION REQUIREMENTS
Billing and Coding: Outpatient Physical and Occupational Therapy Services
- TIP: when you get to the document use Ctrl+F, type what you are looking for in the little box, enter
- 8 min rule, most productive way of billing
- Documentation examples from Medicare with time examples
- Plan of Care
- Progress Reports, Re-Evaluations requirements ever 10 treatments or 30 days, whichever is first
- Certifications, Re-Certifications
- Discharge summary requirements