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Appealing a Denial for Skilled Therapy Services

Posted on: October 25, 2013

Appealing a denial for skilled therapy services can be a daunting task rife with stress.
However, most Fiscal Intermediaries (FIs) or Medicare Administrative
Contractors (MACs) send specific guidance on information they need to see in a
denial. As this information sometimes differs, the following is an outline of
general information that many have found to be helpful.  

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Tags: nursing home operations, nursing home occupancy, RUG IV, skilled nursing facility, medicare

Medical Necessity Continues to Dominate Documentation Audits

Posted on: March 5, 2012

                            Redefining Partnership.  Rethinking Therapy.

                          HealthPRO Rehab Advisor

Contact Information

Crista Stark

SVP, Sales & Marketing 

Dave Boerkoel, OTR

SVP, Clinical Operations

 HealthPRO website







Join us at the 2012 AJAS Annual Conference 
in Palm Beach Gardens, FL
March 19th

BOOTH #109




Welcome to the HealthPRO Rehab Advisor!   

This newsletter is a service to our valued customers, offering updated information about industry issues, as well as news regarding HealthPRO's programs and services.


Medical Necessity and Documentation

Medical Necessity" is "THE" hot topic these days in our industry as a result of the increase in pre-payment and post-payment audits being conducted by Medicare and third party payers.  Headlined in most Healthcare Journals, newsletters and Online is the following tag line -Medical Necessity will continue to Dominate Documentation Audits.  

The stakes are continuing to be raised on provider compliance and implications for therapy providers increase the risks of practice in an era of fraud and abuse scrutiny.


Medical Necessity has become a key phrase that auditors are quoting when reviewing medical records and is one of the top reasons for claim denials.  Ensuring that your documentation supports the medical necessity of the service you are providing and billing for is crucial for providers.


Daily and weekly progress notes have become a primary focus area when conducting internal audits. Here are some tangible suggestions to increase your Documentation Integrity!


Progress Notes:


Daily Documentation is required to reflect the skilled services being provided.  Daily documentation should include:


a.    Objective measures of the current level of assistance required for functional tasks.

b.    A description of the skilled services provided.

  • Example:  Non-skilled documentation:  Observed patient brushing his teeth after set up with verbal cues.  The skilled component necessary or the importance of instruction has been omitted in the previous sentence.  Skilled terminology:  The occupational therapist provided verbal cues to instruct the patient in a compensatory strategy for using one hand to sequence squeezing the toothpaste onto the toothbrush, running the water and brushing the teeth with the appropriate end of the toothbrush.  These specific instructions provided to the patient were important to the patient learning the task.

c.    Assessment of the patient's response to the services.

d.    Progress towards the treatment goals.

e.    Documentation of any treatment variations with the associated rationale.

f.    Accurate documentation of treatment time in minutes, to be recorded on the MDS.


  Weekly Progress Summary should include

  1. Document the current level of assistance required for functional tasks and compare it to the previous week's status to evaluate the patient's progress.
  2. Determine if progress towards goals has occurred.
  3. If progress towards goals has not occurred, document the possible reasons contributing to the lack of progress.  The goals should be revised or the patient should be evaluated for possible discontinuation of therapy services.  Determine if a functional maintenance program would be indicated.

d.    Document the need for continued services by a skilled therapist verses the use of restorative nursing.

  • Non-skilled services include:  observing or monitoring, general practice techniques, and reviewing previously learned material.
  • Skilled services include:  educating the patient, assessing mobility skills, evaluating the effectiveness of, instructing the patient in a progressive exercise program, or modifying the treatment program.

e.    Document evidence of carryover of the skills learned in therapy to the functional tasks.

  • Examples:  Physical therapy has been working on weight shifting in the parallel bars to allow a patient to take a step, this task is then carried over to the resident's ability to weight shift and take a step with a standard walker.  An occupational therapist may work on overhead reaching exercises with the carryover seen when the patient can reach into the cupboard to get a glass of water without assistance.

f.    Identify the expectation for further progress.

g.    Identify the resident's risk factors that may be eliminated by receiving the therapy services.

  • Examples:  The resident is at a high risk to fall due to balance deficits, the resident is at high risk for aspiration due to delayed swallowing response, or the resident is at high risk for burns due to problems spilling while attempting to drink from a cup.

h.    Justify the frequency, duration and intensity of the treatment.

  • Example:  The resident would benefit from one more week of treatment at five times per week to provide reinforcement and carryover of the functional tasks.  The program will continue with a progression of the exercise program, modifications to the functional maintenance program and completion of staff education with the functional maintenance program.




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Tags: nursing home operations, MDS 3.0, RUG IV, skilled nursing facility, medicare

RUG IV Impacts: Ways to identify process and system inefficiencies

Posted on: January 20, 2012

In response RUG IV refinements stemming from the SNF PPS FY2012 Final Rule, many Skilled Nursing Facilities are taking a close look at the processes and systems they have in place. With downward reimbursement pressure at both state and Federal levels, it’s increasingly important to have an efficient, streamlined operational plan. The best way to equip your facility for these changes is to identify broken processes, uncover inefficient systems and put a realistic plan into place for improvement. Your staff needs efficient, modern tools to perform their jobs effectively, which is why identifying inefficient processes and systems should be a priority.

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Tags: RUG IV, skilled nursing facility

Summary of FY 2012 MDS 3.0 and RUG-IV Changes

Posted on: January 18, 2012

MDS Assessments

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Tags: MDS 3.0, RUG IV

Your Nursing Facility and New RUG IV Refinements PART 2

Posted on: November 1, 2011

Now that new RUG IV refinements stemming from the SNF PPS FY2012 Final Rule are in place, you might be thinking about a plan of action for your facility. With everything else on your plate, you might also be wondering how you will educate your staff and put new processes into place on top of everything else you try to do in a day. Don’t scramble to fill the gaps, let HealthPROÔ guide your facility.

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Tags: RUG IV, skilled nursing facility

Your skilled nursing home facility and new Rug IV refinements PART 1

Posted on: November 1, 2011

Important Acronyms:

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Tags: RUG IV, skilled nursing facility