Tag Archive for: Initial Evaluation

In this third in our series of Blogs asking the question “Is your practice ready for a Medicare audit?” we continue our discussion of the critical importance of the PT/OT Evaluation.

Medicare assigns significant weight to the patient information gathered and presented by the therapist during The Initial Evaluation. The initial evaluation records objective measurable data of the patient’s impairments to establish the baseline for assessing expected rehabilitation potential, setting realistic goals and measuring progress. Let’s explore the specifics of what they require as set forth in: LCD L26884

To support medical necessity, the evaluation should include the following items.

• Presenting condition or complaint: “Why is the patient in your clinic today?”
  • Patients should exhibit a significant change from their “usual” physical or functional levels.
  • Provide an objective description of the changes in function that now necessitate skilled therapy.

NOTE: Simply stating “decline in function” does not adequately justify the initiation of therapy services.

• Diagnosis and description of specific problem(s) to be evaluated:
  • Include area of the body, and conditions and complexities that could impact treatment.
• Subjective complaints and date of onset: 
  • Accurately record this information.
• Relevant medical history:
  • Applicable medical history, medications, comorbidities should be documented
• Prior diagnostic imaging/testing results:
  • Accurately record this information
• Prior therapy history for the same diagnosis, illness or injury:
  • Accurately record this information

NOTE: If the patient has recently had therapy, your documentation must clearly establish that additional therapy is reasonable and necessary at that time.

• Social support/environment:
  • Does the patient live alone, with a caregiver, in a group home, etc.?
  • What level of support is available?
  • What level of independence is required for the patient to be safe in the home environment?
  • Does the home situation have obstacles that the patient must overcome (e.g., stairs without handrails)?
  • What are the patient’s usual responsibilities in the home environment?
• Prior level of function:
  • Functional status just prior to the onset of the treating condition requiring therapy
  • Record in objective, measurable and functional terms

NOTE: This is a key piece of information used for establishing potential, prognosis and in setting realistic functional goals.

• Functional testing:
  • Objectively measure and/or describe the patient’s current level of functioning. Examples, based on the patient’s need, may include:
    • mobility status (transfers, bed mobility, gait, etc);
    • self-care dependence (toileting, dressing, grooming, etc);
    • meaningful ADLs/IADLs;
    • pain, and how it limits function; and
    • functional balance.
• Objective impairment testing:
  • Testing done to determine the source or cause of the functional limitation(s), such as ROM, manual muscle testing, coordination, tone assessment, balance etc.
  • Use concise, objective measurements.

NOTE: You should avoid minimal/moderate/severe types of descriptions when more specific definitions or measurements are available. For example, when measuring shoulder flexion AROM, document degrees of motion, rather than documenting, “Shoulder flexion: minimal loss of motion.”

• Assessment:
  • Summary of the therapist’s analysis of the condition being evaluated based on the examination of the patient.

NOTE: Medical review decisions impacting audit outcomes are based on the information submitted in the medical record. The assessment of the patient is your opportunity to “make the case” for therapy. The clinical reasoning and judgment you employ in assessing treatment should be clearly recorded in this section.

• Prognosis:
  • How likely is the patient to return to his/her prior level of function?
  • What is the maximum improvement expected, given the patient’s condition?

In our next Blog we will examine the Plan of Care.

Genco Healthcare helps practices achieve and maintain a culture of compliance. We also assist Healthcare Attorneys in defending their clients who have been audited or subject to pre-payment review. Consequently, we have our finger on the pulse of precisely what Medicare’s expectations are when it comes to medical documentation.

David Alben
Genco Healthcare
(914) 713-3606
David@Gencohealthcare.net