TWELVE SURE-FIRE WAYS TO GENERATE A DENIAL
1. The documentation does not support the ICD-9 or CPT codes billed.
2. The documentation does not address whether the patient has the potential to benefit from skilled services.
3. The documentation gives no functional reason for referral OR use one of these phrases in lieu of medical necessity: referred by MD; found in routine screen; referred for diet upgrade learn; family request for therapy; referred to determine appropriateness of diet
4. The documentation is illegible.
5. Documentation lacks the information required to even process the claim. Give no functional reason for doing strengthening, ROM, pain management, compensatory techniques, etc.
6. Lack of documentation from nursing to support therapy intervention.
7. Documentation of non-skilled services being billed by therapy. A denial will be certain if you think that terms like this are enough to show skilled intervention:
PT: gait training, transfer training, ther ex, balance re-ed
OT: ADL retraining, toilet transfers, balance re-ed, UE kinetics
ST: dysphagia therapy, yes/no questions, diet assessment/modification, compensatory techniques, pharyngeal constriction tasks, vocal fold abduction tasks
8. Document caregiver education in the plan of treatment but never document in the weekly notes that this service was performed.
9. Dont address the goals when writing up the end of the month information or dont address what occurred in the last few treatment sessions. Let the intermediary guess what was done.
10. Dont address goals on the daily or weekly progress notes.
11. Ignore the setting the patient came from and their functional status in that setting AND set your goals without keeping in mind the patients discharge setting.
12. Dont discuss patients ability to follow directions/participate in therapy when they have Alzheimers or confusion in their medical histories.
*Note: These are things that are not acceptable practices in documentation. They greatly increase the chance of denial. Avoid them.
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