I believe our clinic see patients every 6 months and bills as an evaluation or consult only and therefore does not open a therapy chart. If the patient us appropriate and able to attend therapy then the treating therapist opens the case and the treatment plan and the related progress notes.

Lisa
-----Original Message-----
DTueooens September 27, 2011 5:11:18 pm
To: <xxxxxx@xxxxxxxxxxxxxxxxxxxx>
From: "Erin Singleton" <xxxxxx@xxxxxxxxxxxxxxxxxxxx>
Subject: Therapy Documentation questions

Hi everyone!

So I have a therapist directed question that I am seeking answers for.

My questions are regarding documentation for ALS/neuromuscular clinics.

At our clinic in Fresno the therapists are employed by the hospital and the doctors are a separate entity. On clinic days when all disciplines see the patients we have our own documentation/reports that we complete in order to chart progression, changes and interventions. Those reports are shared with the team treating the clinic patients.

We have run into some questions regarding Medicare guidelines and long term patients with progressive diagnoses. For example, Medicare guidelines require a progress note every 30 days. If we're not able to chart "progress" Medicare requires a short certification period and then a discharge of the patient. The problem with our ALS population is that we're seeing them long term every 90 days. It doesn't make sense to chart a progress note if we're only seeing the patient every 90 days! Also, aside from achieving short goals we will never chart actual "progress" as they define it. Additionally, Medicare wants patients to be seen short term for 90 day certification periods. Of course we're going to be seeing our PALS long term as long as they come to their clinic appt quarterly. According to Medicare it is non compliant to keep a patient's "case" open without clear progress and improvements charted within the 90 certification period.

So that leads me to my questions for you! How exactly do the therapists see your long term neuromuscular patients?? As therapists are you loaned to the doctors on clinic days and just complete clinic notes for the treating physician? Or do you have your own separate documentation you keep?

Here we are treating as therapists employed by a separate entity. Therefore we have to keep Evaluations, progress notes and discharges for our own facility. The problem is that as far as documentation is concerned there are no separate Medicare guidelines (that I'm aware of) for long term progressive patients (when it comes to documentation).

We do not want to be out of Medicare compliance and are seeking any answers from other therapists treating progressive patients in similar settings! Any information is greatly appreciated. Please email or call me directly with your input! Our clinic has been a great asset to our community here and our number one goal second to patient treatment is to stay open and compliant!

Thank you.

Erin Singleton M.A., CCC-SLP
Neuroscience Outpatient Rehabilitation Center
2335 East Kashian Lane, Suite 301
Fresno, California 93701
Office: (559) 459-6056
Fax: (559) 459-2957
Email: xxxxxx@xxxxxxxxxxxxxxxxxxxx

  ________________________________
-------------------------------------------------------
WARNING/CONFIDENTIAL:
-------------------------------------------------------
This email, including attachments, may contain information that is privileged, confidential, and/or exempt from disclosure under applicable law (including, but not limited to, protected health information). It is not intended for transmission to, or receipt by, any unauthorized persons. If the reader of this message is not the intended recipient you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you believe this email was sent to you in error, do not read it. Reply to the sender informing them of the error and then destroy all copies and attachments of the message from your system. Thank you.