Screening Evaluation for Admission to Rehab Unit 
1. Recent documented change in condition. 
2. Must have had a higher level of function (with a few exceptions).
3. Must identify a safety risk within the last 2-4 weeks. 
4. Must show reasonable expectation of significant progress (i.e. cognitively intact, able to follow directions). 
Does abnormal mean non-functional? Abnormalities alone do not justify therapy. Its impact on function is needed to support therapy. 
Goals must be related to a functional activity that can be measured. Write functional level goals, not deficit goals. An example of a deficit goal would be decrease pain from 80% to 30%. 
Goals need to be: 
1. Patient directed. 
2. Have a qualifier (i.e. safely, independently).
3. Related to a functional activity that can be measured. 
4. Should be achievable within 30-day billing cycle. 
An example would be: "The patient will safely ambulate for all ADL's independently."  Do not just document a patient goal of ambulating 50 feet. You must relate why 50 feet is significant (i.e. the distance from bed to bathroom is 50 feet). 

Skill Stabilization/Skill Generalization - use these terms when documenting. 
Skill Stabilization 
For example, what skills would you need to stabilize for safe ambulation? 
1. Balance                     
2. Trunk Control
3. Stride Length
To achieve these skills, you would need to work on improving strength, neuromotor control, etc. Once these skills were stabilized, how do they need to be generalized for improving patient function? 

Skill Generalization 
4. Ambulate Level Surfaces 
5. Uneven Surfaces
6. Inclines
7. Curbs/Stairs 
Again, document what you're doing to generalize these skills.  When documenting goal status you could state goals 1,2,3, have been achieved, but still working on,4,5, and 6. Denial rate should be low with this form of documentation. 
If a physician designates the # of days/wk a patient is to be seen, you need to follow this, unless you clarify any changes with the physician and he signs off on it, 
Progress Notes 
1. Must show skilled level of complexity 
2. Must report patient's response to treatment (document patient progress).
 3. Must relate to stated goals. 
If you treat a patient outside of the goals you have set, you will be denied. 
Level of complexity - terms such as: instructed / educated in the use of progressive exercise / trained in the following techniques … show a complex level of treatment. Words such as: encouraged / motivated / helped … do not indicate such level of complexity and would be denied. Read your notes and ask yourself: "Could anyone provide the services I've just described, or does it indicate that it is of skilled level complexity?" 
Progress Notes must show significant progress related to functional outcomes. 
If lack of progress occurs, you will be reimbursed as long as   .you can show you transitioned to another strategy of treatment with the expectation of improvement in functional skill level with this new strategy. 
If you see a patient with the primary problem of pain, you will have a lower denial risk if you address function as it relates to the patient's pain. Such as: A patient's painful posture will increase the risk for muscle weakness / imbalance which if continued could cause joint dysfunction/weakness causing a risk of safety with transfers and ambulation. 

Patient/caregiver training can justify treatment for the patient with dementia as long as the caregiver is present during the treatment and that this is documented. 
Rehab will be reimbursed for a one-time evaluation as long as the patient was provided a home program. 
80% rule - Reviewers use this rule. It is that once a patient has achieved 80% of goals, he/she is considered functional. 

Continuing Treatment 
Physicians must physically see the patient every 30 days, and sign a new script to extend the patient's orders. 
When requesting additional coverage for the patient you must list the same things as you did in the initial evaluation, however now you have the past 30 days progress to support your statement of expectation for progress. 
1. List current deficits/safety issues. 
2.  Level of assistance required to perform functional activities. 
3.  Any complications 
4.  Show skilled services that are needed. 
5.  Positive expectations for improvement. 
6.  Likely outcomes if services are not provided. 
Medicare Managed Care Providers are required to follow the same guidelines for their patients as applies to non-managed care Medicare patients. As long as the patients meet these requirements for continuation of services, they cannot be denied visits. 
Managed care companies do want us to believe this is not the case, however. 
Coordination of Documentation across the Disciplines - It is very important that there is agreement between the disciplines on the level of independence/function of the patient when documenting. It the documentation is not in agreement regarding the patient's, skill level, services may be denied. 

Chart Review Outline for Evaluations Look at:
Diagnosis 
Specific Deficits to be treated
Why is it important to treat now?
Skilled services to be provided
Expected outcome