Frequently Asked Question of the Month:
What are the documentation requirements for maintenance therapy?
Documentation: when the skilled service is being provided to either maintain the patient’s condition or prevent or slow further deterioration, the clinical notes must include the information normally contained in a home health clinical note, but also describe:
- A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences,
- The complexity of the service to be performed, and
- Any other pertinent characteristics of the beneficiary or home that would support the unique needs of the patient.
The notes should clearly define the purpose of the visit, that is whether the service was restorative or maintenance in nature, because HHAs must code the visits differently on their claim form.
Symbria is committed to maintaining a high standard and level of communication with our clients and employees regarding clinical education, PDGM understanding, patient assessment, home health regulations, and coding efficiency. As a result, the Home Health Insider was born. In this monthly offering, we hope to provide some valuable information that can foster a quality level of care that meets the needs of the patients that we serve.