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Dementia FAQs - Dementia FAQs

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Dementia FAQs

Medicare and Documentation of Therapy Progress

Answer

CMS states that therapy services shall be payable when the medical record and information on claim form consistently and accurately report covered therapy services. Documentation should also include objective measures of the patient's improvement as a means to justify therapy services. Documentation should justify the necessity of the services provided during the reporting period, and include objective evidence, or, clinically supportable statement of expectation that the patient's condition has the potential to improve, or is improving, in response to therapy, with maximum progress yet to be attained, and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

Objective evidence consists of standardized patient assessent instruments, outcome measurement tools or measurable assessments of functional outcomes. Use of objective measures at the beginning, during and after treatment is recommended to quantify progress and support justifications for continued treatment. Such tools are not required, but their use will enhance the justification for needed therapy and repeat evaluations, including the MBSS.

Diagnostex, August 2012 Newsletter, Ronda Polansky MS, CCC-SLP

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