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Your Top Choice in Continuing Education
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Documentation Bootcamp for

Skilled Therapy Services
Supporting Denial-Proof Medicare Documentation
For more than 23 years John Adamson, PT, M.Div., GCS, has worked in physical therapy
in a variety of settings. A highly credentialed documentation auditor and recognized as
a Master Clinician, Mr. Adamson is involved in ongoing chart audits for state and federal
compliance, as well as for reimbursement.
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About Today’s Instructor

For more than 23 years John Adamson, PT, M.Div., GCS, has worked in physical therapy in a variety of skilled
nursing, acute care and home care settings as a clinical specialist, consultant and trainer. Mr. Adamson is
involved in ongoing chart audits for state and federal compliance, as well as for reimbursement, and has assisted
in Medicare audits, including ADRs and appeals. Mr. Adamson is a credentialed documentation auditor and
recognized as a Master Clinician in documentation and Complex Disease Management, as well as a Geriatric
Enhanced Modality Specialist. In his current role as Clinical Specialist, Mr. Adamson is responsible for ongoing
oversight and instruction of therapists and nursing professionals in the areas of vestibular and balance disorders,
continence, dementia, diabetes, pain management, seating and positioning, wound care management and
modalities utilization. Mr. Adamson has also developed a PRN clinical orientation manual and contributed to an
orthopedic course for the post-acute patient. One of his primary goals is to instruct therapists on the practice
of consistent, solid and irrefutable documentation to substantiate medical necessity and prevent denials. Mr.
Adamson received his degree in Physical Therapy from Northeastern University in Boston, Massachusetts.
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Documentation Bootcamp
Preschoolers & Autism for
Skilled
Keeping CalmTherapy Services
When They’re Carrying On
Supporting Denial-Proof Medicare Documentation
Program Evaluation Form

Summit Professional Education works to develop new programs based on your comments and suggestions, making your feedback on the program
very important to us. We would appreciate you taking a few moments to evaluate this program.
John Lee,
Instructor Name: Cindy Adamson,
M.S.EdPT, M.Div., GCS Location Attended: Date:
May we use your comments and suggestions in upcoming marketing materials? Yes No
Please rate the following items on a SCALE of 1 = (poor) to 5 = (excellent).

1 INSTRUCTOR ____ Teaching ability ____ Organization of material ____ Knowledge base ____ Effectiveness
Please comment on the instructor’s presentation:

2 CONTENT ____ Relevance/value of information for your work ____ Usefulness of hand-outs/visuals
____ Content matched the stated objectives ____ Meeting facility & accommodations
____ Completeness of coverage of materials ____ Convenience of meeting facility location
What was the most beneficial part of the program?
The least beneficial?
What would you like to see added to the program?

3 OBJECTIVES
After attending the program, how well do you feel you are able to:
__ѩIdentify the
ѩ early warning signs
therapist’s of scope
specific potential autism spectrum
of practice disorders
as it relates in select
to patient preschool children.deficits.
of functional
__ѩSelect
ѩ Identifyappropriate treatment
key underlying approaches
impairment categoriesfor preschool
that provide children.
the basis for skilled assessment, and ID appropriate tools for assessing them.
__ Identify the difference between atypical and typical developmental patterns.
ѩѩUtilize assessment of functional deficits and underlying impairments to choose an appropriate treatment diagnosis and write a string reason
__ Select instructional strategies/interventions that are appropriate for the presenting characteristics
for referral.
(behavioral, cognitive, social, emotional, sensory).
ѩ
__ѩPlan
Selectforappropriate
structured data from the MDS
and organized to formulate
facilitation SMART
of play goals.
and socialization.
__ѩDescribe
ѩ Determineways to support
appropriate families through
interventions the period
based upon of diagnosis
data and and throughout early development.
assessments.
ѩѩProvide appropriate analysis of update progress notes.
ѩѩJustify current plan of care and future skilled interventions at mandated intervals.
ѩѩEvaluate when discharge of care is appropriate, and justify entirety of care plan from SOC to discharge.
Please tell us what other programs or topics might interest you?
(fill in the blank) (fill in the blank)
(fill in the blank) (fill in the blank)
If you have any general comments on this topic or program please explain. You may use the back of this form to elaborate.
Name: Professional Title: Setting/Population:
(Optional) Thank you for participating and taking the time to join us today!
Logistics
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End of day
Bootcamps
Temp
Documentation
Boot Camp
Supporting Denial Proof Medicare
Documentation Plan of Care to
Discharge
By John Adamson, PT, MDiv, GCS
johndadamsonjr@gmail.com
Find me on LinkedIn
The Rehab Documentation Guru- YouTube channel
8
Bio
BS in PT June, 1991, from Northeastern
University, Boston, MA
Mixed background in care settings
Married with 6 biological and 3 adopted children
(special needs, from Ukraine)
MDiv from Southern Seminary, Louisville, KY
May 2007- started with Aegis
October 2010- started as Clinical Specialist
Documentation Auditor, course presenter, clinical
mentor
Appeals Management
Recently passed the APTA Board Certification for
Geriatric Clinical Specialist (GCS)
Objectives
Discuss the rising cost of Medicare and cost cutting measures to
therapy services.
Differentiate between “reasonable” and “necessary” and their
impact on payment of therapy services.
Distinguish between functional deficits and underlying
impairments.
Discuss the principles behind choosing appropriate selection of
ICD codes
Formulate strong and comprehensive reasons for referral
Develop SMART goals
Choose appropriate frequency and durations of care
Select CPT codes that represent the findings of the assessment of
the patient.
Justify current plan of care and future skilled interventions at
mandated intervals
Formulate a comprehensive discharge plan that exhausts the
discipline scope of practice
Determine appropriate reasoning for choosing functional limitation
coding levels
9
Documentation- where we were…
Prior
to advent of Medicare, there
were no real therapy documentation
standards
– Rubber stamp story…
Cost of Medicare vs. Inflation
Costof living in 1966 compared to

today:
– $1.00 in 1966 would be worth $7.29 in
2015 dollars, and 729% increase.
(http://www.bls.gov/data/inflation_calc
ulator.htm)
Medicare cost % increase since
inception (2013): 16,400%
10
Medicare A cost control
On July 1, 1998, all inpatient entities
billing for post-acute part A services
became responsible for controlling
their costs according the flat fee they
made based upon the RUG system.
PPS system is in 4th version, all
changes occurring to assist with
further cost control.
Medicare B cost control

Medicare part B caps:
– 2015 levels- PT and SLP $1940; OT $1940
Manual Medical Review Process:
– Automatic review (ADR- Additional
Documentation request) at $3700 for PT/ST
combined; $3700 for OT.
MPPR- Multiple Procedure Payment Reduction:
– 50% reduction in payment of “practice
expense” portion of each code billed after first
one paid in full. As of 8/2013, this had driven
cost/visit (therapy services) down 8%.
http://www.clinicient.com/2013/08/medicare-
multiple-procedure-payment-reduction-mppr/
11
Results of decreased reimbursement/changes to
payment/recovery efforts
RAC (Recovery Audit Contractors) has recovered

more than $7 billion in over payment since 2009.
(http://ehrintelligence.com/2013/11/07/suspensi
on-of-rac-audits-could-cost-medicare-2-billion/
$717 billion in cuts expected over first 10 years
of Affordable Care Act.
(http://www.nydailynews.com/opinion/seniors-
hurt-obamacare-article-1.1504414)
Each year since 2010, significant changes have
occurred with Medicare regulations, impacting
reimbursements.
Where that leaves us…

We need to prove…
–medical necessity exists…
12
Skilled Necessity= “reasonable and
necessary”
“Reasonable” care:
–Reasonable- Weighing costs with
benefits, care is generally
predictable in duration and
intensity, based upon best clinical
practice and research. Medicare
has had hard time establishing
this.
(http://www.nejm.org/doi/full/10.1
056/NEJMp1208386)
“Necessary”
The service of a physical, speech-language
pathologist or occupational therapist is a
skilled therapy service if the inherent
complexity of the service is such that it
can be performed safely and/or
effectively only by or under the
general supervision of a skilled
therapist.
(http://www.health.state.mn.us/divs/fpc/
profinfo/ib03_2.htm)
13
Skilled Therapy must meet the following
requirements:
Evaluation completed by a licensed therapist,
certified/signed and dated by a physician/NPP(non-
physician practitioner- may be, in some cases, CNP, PA, or
clinical nurse specialist, as defined by state practice acts,
and depending on whether they have a separate NPI), with
physician NPI number. Certified outpatient rehabilitation
facilities (CORF) must have MD signature, not a NPP.
Require the special skills and knowledge of a therapist to
intervene.
Improvement is expected in reasonable time, requiring the
therapist’s skills, or the therapist is required to
initiate/adjust a restorative maintenance program.
Accepted standards of medical practice are utilized.
(scientifically supported)
Accepted intensity and duration.
(http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/bp102c08.pdf)
Un-“Skilled” services are…

Unsupported by MD approval
Can be carried out by non-skilled
personnel
Repetitive in nature without
demonstrating special skill/knowledge of
therapist
Palliative/maintenance in nature*
Do not utilize accepted standards of
practice
Demonstrate excessive frequency,
intensity and duration to accomplish goals
of treatment
14
But… “Necessary” kind of trumps
“Reasonable”
Glenda Jimmo, et al vs. Kathleen Sebelius
– Clarified Medicare regulations already in place…
“While an expectation of improvement would be a
reasonable criterion to consider when evaluating,
for example, a claim in which the goal of
treatment is restoring a prior capability, Medicare
policy has long recognized that there may also
be specific instances where no improvement
is expected but skilled care is, nevertheless,
required in order to prevent or slow
deterioration and maintain a beneficiary at
the maximum practicable level of
function.”(http://www.fairfaxcounty.gov/dfs/olderadults
ervices/ltcombudsman/fact-sheet-for-jimmo-sebelius-
settlement.htm)
Proving Skilled Necessity of Care

leads next to…
Scope of Practice:
What does your degree qualify you to
perform?
LCD- Local Coverage Determinations
NCD- National Coverage Determinations
State Practice Acts
Professional Advocacy Groups
15
Functional Deficits vs. Underlying
Impairments
Functional deficits are…
– measurable (i.e., SBA, min assist, total assist)
– Generally observable by all people, not just skilled
practitioners, and alert people to a “problem” that must
be “fixed.”
– Addressed, depending upon the issue, by one or more
practitioners (not necessarily discipline specific)-
example- loss of upper extremity function
– Are what the insurance companies are wanting to
see addressed.
– Must be compared to Prior Level Of Function (PLOF)-
before medical dx/treatment dx occurred that caused
RFR
– Answer “WHAT” is going on?
Functional Deficits vs. Underlying

Impairments (continued)
Underlying impairments are…
– Measurable (e.g.-special standardized tests, ROM,
strength, balance, etc)
– Are generally specific to a certain scope of practice of a
skilled practitioner, and are not inherently
observable/measurable to a non-skilled professional.
– Addressed, depending upon the impairment, by one or
more skilled practitioner scopes of practice (e.g.- PT and
OT can both address ROM of an extremity)
– Cause the functional deficit, prove the need for
skilled services, form the basis for goals and
analysis, and demonstrate the need for chosen
interventions (CPTs).
– Answer “WHY” is this going on?
16
Functional Deficits and Underlying
Impairments- examples
PT
– Patient has a limp and cannot walk
>100 ft before needing a break
Measurable
Observable by all people

Can be addressed by one of more skilled
professionals (definitely within PT scope)
This observation alone is not necessarily
skilled

Impairments- examples (continued)
PT (continued)
– What is causing the limp/limited walking
distance?
Circumference of knee is 6 cm > than other side
Knee extension during heel strike is -25 degrees
Patient reports 4/10 pain at rest, 7/10 pain after 100
ft of ambulation, exacerbated by WB.
Quads demonstrate 3+/5 strength, with pain.
– What makes these different from functional
measures?
They are not necessarily readily observed by non-
skilled personnel/non-therapists, and certainly not
measurable by many, or make clinical sense to but a
few.
17
OT
– Patient cannot put on shirt unless it is button
down. (functional impairment)
– Patient exhibits the following underlying
impairments:
Right shoulder ROM is limited to 70 degrees scaption
actively.
When pulling shirt over her head, she loses balance-
therapist determines that patient has vestibular
and/or proprioceptive issue due to 1) loss of visual
input and 2) position change of head disorients
patient.

ST
– Patient cannot swallow without coughing
(function)
– Patient exhibits the following findings to
a SLP (underlying impairments)
Poor mastication due to loss of dentition
Decreased tongue strength and ROM, thus
making bolus propulsion difficult
Rapid breathing, making airway closure
coordination difficult
18
Do you see the importance?
Without a functional deficit, no
skilled intervention is needed…
Without assessment/analysis of
underlying impairments causing
functional deficits, we will not be
able to prove our particular
(discipline) services are required…
Bootcamp exercise 1
Using patient scenario 1, chose for
your discipline the underlying
impairments that may be causing the
patient’s functional deficits.
(page 64)
19
Impairments…
Recap…
– Functional deficits are what anyone can see,
but still need to be measured (which requires
some skill), and are the basis for referral to
therapy.
– Underlying impairments are only what the
skilled practitioner can see, cause the
functional deficit, and form the basis for skilled
assessment, intervention, and analysis.
– With the assist of these 2 areas, we are ready
to start addressing our Reason for Referral
(RFR).
Medical and Treatment Dx

Medical Diagnosis: the art or act of
identifying a disease from its signs
and symptoms (Merriam-Webster)
Treatment Diagnosis:
– Needs to tied in with underlying
impairments assessed
– Helps answer the “why” we are treating
the patient…
20
Medical and Treatment Dx -
continued
Must be Relevant
Must be Current
Must be Active
Must be sufficiently explained in the reason for
referral
Medical diagnosis must have a cause-effect
relationship with the treatment diagnosis
Code to the highest level of specificity and
complexity of the patient, as long as it is
relevant to the patient’s therapy case/RFR.
Medical and Treatment Dx

(continued)
Just as functional deficits are caused
by underlying impairments,
treatment diagnoses are caused by
medical diagnoses.
Once you have ID’d your medical dx,
treatment dx, functional deficits, and
underlying impairments, you are
ready for writing the…
21
Medical Dx - caution
Medicalconditions (UTI, dehydration,
GI issues, pneumonia, etc)
– Will require additional supporting documentation if
therapy is involved (generally nursing, MD, activities)
– For many medical conditions, the assumption on
Medicare’s part is that the patient’s function will improve
as they recover from their illness and through nursing
activities
Therefore, please describe the complexity of the patient

and the intricacies of the treatment needed to justify,
“Why You” and why not just nursing (i.e. they can walk
the patient to the dining room, restorative can provide
cueing to get out of bed)
Reason for Referral (RFR)

Your sales pitch to Medicare or any
insurer.
Tells a brief story of “what changed?”
and “why now/why me?”
Accounts for a significant portion of
the reimbursement picture of your
plan of care/start of care.
22
How to write a RFR
3 main components make a solid RFR:
1) The medical and treatment dx, and how they
relate to one another. (what changed?)
2) A brief summary of the functional deficits,
and the underlying impairments that cause
them. (what changed?)
3) A statement of medical necessity of care
(why now/why me?)
4) As an added bonus- it is a good idea to
include any significant co-
morbidities/complexities (age, severity of
condition(s), acuity, social circumstances)
that may impede progress/impact therapy.
Sample RFR
“Patient is a 78 y/o male with left CVA on ____
(date), resulting in right hemiparesis. The
patient presents to PT with difficulty performing
bed mobility, transfers, and level ambulation, due
to significant weakness of right LE, hypertonicity,
decreased balance, and poor safety awareness.
Patient also has a h/o DM with recent
uncontrolled blood sugar levels, and was found to
be at 370 mg/dl on admission, placing patient at
risk for ketoacidosis with unmonitored activity at
high blood sugar levels.
Skilled PT is necessary due to patient is at
significant risk for falls with injury, dependence
upon caregivers for mobility, decreased
independence, and need to return to PLOF. In
addition, unmonitored activity at high blood
sugar levels places patient at risk for metabolic
dysfunction.
23
Another Sample RFR
“Patient is a 91 y/o female with h/o Alzheimer’s Disease,
referred by nursing for a therapy consult secondary to
patient sliding down in gerichair. Patient has been in a geri
chair for 4 years and presents to occupational therapy with
significant contractures, decreased arousal due to reclined
position and inability to interact with environment,
decreased self feeding ability, and recurring skin issues due
to shear forces from sliding in chair from increased tone.
Patient also demonstrates significant cognitive impairment,
and cannot self-reposition adequately, so will require
extensive seating system modification for pressure relief
and postural support, as well as caregiver training.
Skilled OT is necessary due to patient is at risk for falls out of
chair, further contractures, acquired pressure ulcers,
decreased socialization, increased dependency upon
caregivers, and decreased quality of life. OT is expected to
restore patient’s safety in a seating system, and improve
these risk factors.”
And one for Speech…

“Patient is a 42 y/o MVA patient s/p TBI with significant h/o
dysphagia, who has been on mechanical soft diet with
nectar thickened liquids for the past 3 years. Patient’s
caregiver noted in last 2 weeks significant coughing with
drinks and loss of food from mouth, with increased
lethargy. Patient had recently had change in Baclofen
dosage to manage tone, but patient at this time requires
altered dosage due to benefits of managing tonal issues is
required for patient’s functional mobility, and it is medically
contra-indicated to discontinue dose change at this time per
MD orders. Patient presents to ST with oral-pharyngeal
dysphagia, with decreased labial closure, decreased bolus
propulsion, decreased airway protection, delayed swallow
response, and decreased arousal.
Skilled ST is necessary due to patient is at risk of
penetration/aspiration with associated complications,
potentially including death. ST is expected to improve
patient’s swallow function to PLOF.”
24
What are examples of poor RFRs?
“PT screened patient per nursing
recommendation of decreased transfer
ability. Patient also noted to require assist
for gait. Therapy recommended.”
“Patient demonstrates difficulty with splint
fitting hand, and requires this for feeding
and ADLs.”
“Patient referred to ST for recent weight
loss of 10 lbs in 3 weeks. Patient is
currently on pureed diet.”
Relating the medical and treatment

dx
There must be a logical correlation
between the 2 that are chosen:
– “DJD of knee” ties in well with “difficulty
walking.”
– However, sometimes you have to spell
out the relationship (example- COPD
and dysphagia)
Certain FIs/MACs have certain
combinations of diagnoses that are
forbidden- check on this.
25
Writing a strong RFR
Easyenough when there is an acute
event:
– CVA x 2 weeks ago (medical dx)
– Treatment dx could be related to most
significant findings (e.g., patient has
hemiparesis which is causing a number
of underlying impairments.
Writing a strong RFR (continued)

Hard to do when the change in
function is not evident, or expected
change with therapy not likely.
– Patient has been in geri chair for 3
years without change in function…
– Patient with recent dx of end stage CHF
with EF of 15%...
– Patient with MS who is experiencing one
(in a long line of recent) exacerbation…
26
Can be hard to do when patient is
improving…
– Patient is awakening from comatose
state…
– Patient received modification to
Parkinson’s meds and is moving much
more freely…

What is the basis for skilled therapy:
– “…Medicare policy has long recognized that there may
be specific instances where no improvement is expected
but skilled care is, nevertheless, required in order to
prevent or slow deterioration and maintain a beneficiary
at the maximum practicable level of function…”
– The Omnibus Budget Redconciliation Act 1987 (OBRA)-
The law requires nursing homes to care for the
residents in such a manner and in such an environment
as will promote maintenance or enhancement of
the quality of life of each resident. A new emphasis
is placed on dignity, choice, and self-determination for
nursing home residents.
27
Resident Rights
– Take these into account when
determining medical necessity of care
as it relates to your scope of practice to
address.
Boot Camp exercise #2

Refer to Handout 2b, “BOOT CAMP
EXERCISE 2: WRITING THE REASON
FOR REFERRAL.”
Practice in groups of 2-3 same
discipline individuals to come up with
a strong RFR.
28
Goal Writing
Goal writing should demonstrate…
– A correlation between functional deficits
and underlying impairments.
– Objective benchmarks.
– Skilled analysis, and basis for further
analysis.
Goal Writing- SMART goals

SMART…
– Specific- area of function- be specific
– Measurable- if it is not measurable, you cannot
address
– Attainable- is it something we can achieve-
ties into prognosis
– Relevant- does it have bearing on patient
rights? PLOF? Our scope of practice?
– Time-constrained- There is a end in sight- may
not impact “maintenance therapy”
29
Goals continued
STGs
– Medicare does not necessarily require STGs
– However, STGs allow more specific and
thorough analysis of patient progress
– There should be obtainable goals for any
patient within the minimum reporting period
(ie, 10 treatment days).
– Point to LTGs and are generally more specific
– Some MACs are requiring STGs, even though

Medicare policy manual does not make
mandatory.
Goals continued
LTGs
– Are required
– Need to be measurable functionally
– Give the picture of what the end result
of care will look like- what we envision
the patient to be like when we are all
done with him/her.
– Will be related to ICE model of care in
terms of frequency/duration.
30
Mechanics of writing a good goal
Very simple…
– Functional deficit
– Underlying impairment
– Time frame for achievement
What should not be in the goal

The skilled intervention you are
using to achieve the goal- goals are
independent of therapist
intervention-eg, putting application
of ES in a goal.
Vague descriptors of patient
progress/ill defined objectives
Lack of time frame for achievement
31
What should not be in goal
Least restrictive
Maximize function
Maximize level
Highest level attainable
endurance” or “functional
endurance” or “activity
tolerance”
Examples of goals
“Patient will perform sit to stand transfers
with SBA due to right knee flexion ROM
>=95 degrees to allow normalization of
transfer dynamics in 2 weeks.”
“Patient will demonstrate 3+ grade Kansas
University sitting balance assessment to
allow bilateral UE usage in seated dressing
to allow donn/doff of shirt SBA in 2
weeks.”
“Patient will demonstrate no anterior
spillage on 9/10 trials as evidence of
improved labial closure, to improve bolus
cohesion, in 2 weeks.”
32
Examples of goals- continued
(assume all goals 2 weeks)
“Patient will demonstrate decreased scissoring to
once <=10 steps to allow CGA gait with walker
on level surfaces.”
“Patient will demonstrate use of long handled
show horn to donn shoes mod IND due to lack of
ability to bend trunk forward without significant
DOE, and will perform with RLA dyspnea of 2+ or
less.”
“Patient will be IND with self-relaxation
techniques prior to verbal output as evidenced by
<=1 repetition of syllables per sentence, to make
speech intelligible and make needs known.”
Examples of weak goals

“Patient will ambulate 150 ft to allow
improved ability to go from room <>
dining room.”
“Patient will increase UE strength to
5/5 to allow IND UB dressing.”
“Patient will improve
safety/judgment to 90% in order to
function more safely in d/c
environment.”
33
Goal Writing- continued
Remember-
– Functional Deficits are what brings the patient
to therapy in the first place, and need to be
specifically addressed in goals.
– Underlying Impairments are what cause the
functional deficits, demonstrate the specific
skills of the therapist to determine, and form
the basis for further analysis and chosen
interventions.
– Tying these 2 together in the goal is essential
to proving skilled need.
ICE model of care- application to

goals
Improve Impairments- improving the
underlying impairment
– Example: “Patient will have 3+/5 strength in
right elbow flexion to allow IND self
feeding/bringing food to mouth.”
Compensate for Impairments- the patient
makes up for an underlying impairment
that he/she cannot improve
– Example: “Patient will demonstrate IND
feeding with left hand due to inability to bring
right hand to mouth due to R UE weakness.”
34
goals
Environmental adaptations- the
environment or caregiver’s behavior is
modified to accommodate an underlying
impairment for which the patient can
neither improve or compensate for, thus
improving function
– Example: ”Patient will be appropriately set up
in wheelchair by caregiver 5/5 presentations,
to allow patient to stay up for 2 hours, to allow
patient to attend full meal and one activity,
demonstrating proper alignment and report of
pain <=3/10 by end of 2 hours.”

goals
Why is ICE important to consider:
– Not all patient underlying impairments
are improvable, nor will all patients be
able to compensate for the deficit.
– If treatment focuses just on
improvement goals, it limits the amount
of acceptable therapeutic interventions
that you can deliver to the patient.
– It has a direct impact on patient
prognosis.
35
Goal dynamics- not always a 1:1
ratio of FD to UI
Sometimes one underlying impairment
with address >1 functional deficit, and
vice versa
It is OK to bundle these together in a goal
to eliminate excess goals:
– “Patient will improve R quad strength to >=4/5
and R knee flexion to >=110 degrees to allow
reciprocal stair climbing.”
– Patient will improve right shoulder ROM to
>=100 degrees to allow IND shirt donning
overhead and IND reaching into cabinets for
food retrieval.”
Use of MDS (Minimal Data Set)

data for functional goals
You will need supportive
documentation from nursing to assist
with supporting referrals and denials.
Changes in MDS data from 1
assessment to the next are sufficient
grounds for demonstrating nursing
documented changes in function.
36
Use of MDS data for functional
goals- continued
ST MDS sections to look at: B (Hearing, Speech,
and Vision- B1-6), C (Cognitive Patterns- all
sections), D (Mood- all sections- mood impacts
cognition, swallow), E (Behavior- all sections), F
(Preferences for customary routine, activities,
community setting), G (Functional Status- G1a),
I (Active Disease State- Nutritional), J (Health
Conditions- J10-11, 16 [fall hx], K
(Swallowing/Nutritional Status), L (Oral/Dental
Status), Section O (therapy section for all
disciplines), Q (Participation in Assessment and
Goal Setting- all)

goals- continued
OT- Section B (Hearing, Speech and
Vision- especially B7-8 on vision), C
(Cognitive Patterns), D (Mood- all
sections), E (Behavior), F (Preferences for
customary routine, activities, community
setting), G (Functional Status- all), H
(Bladder and Bowel- H2-4), J (Health
Conditions- all sections), K
(Swallowing/Nutritional- within OT scope
of addressing), M (Skin Conditions), O, P
(Restraints), Q (Participation in
Assessment)
37
goals- continued
PT- B (section on vision- impact on balance), C (cognition-
will impact patient safety with mobility), D (Mood- may be
reflective of loss of functional mobility- cross reference with
other areas), E (Behavior- same issue as D), F (pursuit of
activities involving mobility), G (functional status), H
(bladder and bowel), I (active diseases and impact on
mobility), J (Health conditions- especially pain, SOB, angina
with activity, falls), M (skin conditions), O, P (restraints), Q
(participation in goals)
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-
Instruments/NursingHomeQualityInits/downloads/MDS30Dr
aft.pdf
One more thing about goals…

If you stated that something was an
issue in the reason for referral, you
had better have a goal for it…
38
Boot camp time…
Refer to “Goals Practice Time
Worksheet”
Break up into groups of 2-3
individuals of same discipline and
attempt to address all underlying
impairments and all functional
deficits with goals.
Choosing appropriate interventions

(CPT codes)
CPTs are determined based upon
your underlying impairments that
you are addressing.
CPTs should not be chosen to cover
something you might want to
address in future.
CPTs should all be addressed
according to frequency and duration
of MD orders- no “floating” CPTs
39
CPT codes- continued
Determined by your LCD (Local Coverage
Determination) by your MAC (Medicare
Administrative Contractors)/FI (Fiscal
Intermediary)
We are not going into detail concerning choice of

CPTs and ICD-9s since this is dependent upon
your FI/MAC. Be sure to get a LCD for your
practice/per insurer and adhere to definitions and
restrictions outlined on the LCD.
BTW- ICD-9 is replaced by ICD-10 on 10/1/15.
Boot Camp time

We are not going to do a CPT boot
camp- we are coming back to
justifying these in our treatments-
questions about choosing appropriate
ones?
40
Progressing with treatment
Plans of care/initial evals cover
medical necessity of care until first
required reporting of progress (10
treatment days)
It is essential that the progress
reports/notes, and updated plans of
care demonstrate the continued
medical necessity of care.
Essential elements of progress

reports
Change in function
Skilled Analysis
Skilled Interventions
Adjustments to care
Impact upon burden of care
Continued frequency and duration
Prognosis
41
Change in Function
Each progress note should demonstrate clear,
objective, and timely improvement (goes back to
reasonable criteria of care).
Goals should be documented upon with same
functional and underlying impairment criteria.
If no change occurs, this will put greater burden
on skilled analysis, skilled interventions, and
adjustments to care.
If change occurs in FD but not in UI, or in UI but
not FD, this may demonstrate need for further
analysis concerning relationship of the 2 in the
goal.
Skilled Analysis
Based upon data entered into goals
Demonstrates critical thinking through functional
deficits and underlying impairments comparison
Gives opportunity to explain lack of progress
Allows for further assessment of underlying
impairments that may be impacting function
If patient is on skilled maintenance, can discuss
why continued skilled service is necessary
Answers the “why?” progress/”why not?”
progress.
42
Skilled Analysis- continued
Examples of statements:
– “Functional progress in ___ this past week/2
weeks/month has been significant due to
improvement in ___.”
– “Patient accepts greater challenges in ____,
thus allowing improved performance of ____
functional task.”
– “The patient did not make significant progress
this note period due to ____. Please note
update to plan of treatment to address this
lack of progress. Skilled interventions have
still been required during this time due
to______.”
Boot camp time…

Using provided information on
“Skilled Analysis Boot Camp,” using
discipline specific case scenario,
write a skilled analysis.
43
Charges entered by therapist as CPTs
CPT- Current Procedural Terminology
(CPT) is a code set that is used to report
medical procedures and services to
entities such as physicians, health
insurance companies and accreditation
organizations.
(http://searchhealthit.techtarget.com/defi
nition/Current-Procedural-Terminology-
CPT)
CPT Documentation
It is important that all CPTs have a clear
relationship to the underlying
impairments/functional deficits-
– Example: manual therapy should have a clear
relationship with objectively measured edema,
joint and/or soft tissue play, etc.
All CPTs that were billed during the
interval between last to current
documentation should be explained. Any
that are not explained should not be
billed.
44
What skilled intervention means…
Itis not a description of what the
patient did necessarily (though this
may be part of it):
– Example: “Patient performed 3 sets of
10 reps shoulder flexion with 3#
weighted dowel.”
Itis a description of the special
skills/techniques/analysis that you
provided.
Let’s make the last statement

skilled-
“Therapist facilitated normalization of
scapulothoracic rhythm during
resisted shoulder exercises, to
strengthen scapular plane abduction
for functional tasks, by cuing for
scapular retraction, to decrease risk
of glenohumeral impingement.”
45
Use Action words…
– Analyzed, assessed, adjusted, modified,
adapted, instructed, upgraded, progressed,
incorporated, inhibited, facilitated, modeled,
normalized, facilitated, reduced (notice words
lend themselves to therapist involvement as
the initiator of the action, not the patient)
– Avoid words/phrases such as continue(d,s),
no change, little change, steady progress, little
or no progress, patient not compliant, the
same.
Examples- PT
“PT has analyzed gait dysfunction over various surfaces,
determining how strength gains improve cadence, which
has necessitated adjustment to verbal cuing to achieve
independent mobility.”
“Electrical stimulation applied to knee extensors right LE
due to terminal extension lag, at 50 Hz on symmetrical
biphasic waveform, at pulse duration of 200 microseconds,
10 seconds on/50 off, with manual and verbal cues to
facilitate >50% effort during on phase for increased motor
recruitment.”
“Application of short wave diathermy on thermal setting to
iliopsoas muscle group, followed by low load stretching with
manual cues to maintain appropriate alignment for
effectiveness, which has led to additional 20 degrees hip
extension, allowing patient to go from step-to gait to step-
through gait.”
46
Examples- OT
– OT analyzed patient’s kinesthetic awareness
of, and determined how postural and extremity
weakness impact advanced bathing activities.
OT applied PRE’s to develop triceps, upper and
lower back strength for bathing due to poor
postural control of thoracic kyphosis and
scapular stabilization problems.
– OT determined most effective cueing strategies
for grooming according to cognitive level and
trained direct caregivers in application of these
cues during routine care, to provide
consistency in training and progress patient
towards carryover, as evidenced by ACL level
of 3.8.
Examples- ST
Analysis of patient’s dentition indicates
that improperly formed bolus is related to
poor mastication, thus requiring at this
time downgraded diet.
Progressed patient to using calendar for
self planning activities based upon A&O x
3 now, with minimal verbal cuing for
proper use of calendar and clock
concurrently to plan day with 3/5 days
planned out appropriately.
47
Poor examples of skilled
interventions…
“Patient performed ambulation 2 x
100 ft with FWW.”
“Caregiver educated in proper
transfer technique, but requires
further training.”
“Skilled interventions included double
swallow, chin tucks, and lingual
sweeps.”
Skilled Interventions Boot Camp

Any questions about skilled
interventions?
(we
will not be doing a specific boot
camp concerning this)
48
Adjustments to Care
Should reflect…
– Analysis of change in functional
status/lack of change
– ICE model of care- how patient is
responding to each component
– Past success/failure of interventions
delivered to date
– Patient’s medical status at time of
assessment
– Any additional underlying impairments
Adjustments to Care
If adjustments to care include a
change in the LTG, then his should
result in a new, updated plan of care that
will need MD approval.
Adjustments demonstrate skilled, non-
functional maintenance or non-restorative
maintenance program aspect of care. This
is important even in programs that qualify
as “skilled maintenance.”
49
Adjustments to care- examples
“Progress patient’s task difficulty from supine to
sit to now transfers due to ability to keep HR
<60% predicted max during bed mobility,
indicating patient ready for activities requiring
greater MET levels.”
“Patient’s development of non-blanchable
errythema over distal thumb indicates splint is
not providing proper contact with digit, and is not
adequately supporting thumb IP joint, therefore
further assessment and adjustment is indicated
to hand splint prior to patient being d/c’d to
caregiver for application.”
“Plan is to decrease frequency of skilled
interventions from 5 days to 3 days per week due
to improvement in ____. With improved
caregiver carryover of facilitation of ____.
Adjustments to care- examples

“Patient’s lack of coughing with 100% of
presentations of ___ consistency indicates
that she is ready for progression to ____
consistency trials, however due to
significant h/o pharyngeal dysphagia will
not be safe for pleasure feedings until
determined safe with ST treatment.”
Do not use “continue(s,d)” or “no
change”- potentially denotes a program
that is capable of being trained to
caregiver and/or patient
50
Adjustments to Care Boot Camp
Using earlier scenario that you wrote
analysis and interventions for, write
2 skilled adjustments to care.
Daily notes?
Record of minutes/units/signature for
billing
SOAP note format
Purpose of the exercise/activity flow

sheet as an adjunct
51
Impact of Burden of Care
Your opportunity to both…
– Brag upon the impact that therapy has
made to the patient’s functionality-
shows $ worth of what has been done.
– Discuss continued challenges (if not
covered in analysis, etc) that patient
faces requiring skilled services.
Impact of Burden of Care -

examples
“Due to skilled PT, patient has improved from
maximum assist with transfers (requiring Sara lift
with nursing staff), to min assist from CNAs, and
up to CGA from therapist with complex cuing for
sequencing of transfer technique.”
“Due to skilled OT, caregivers report that patient
does not attempt night-time toilet transfers IND
because night-time wetting has not occurred in
last week.”
“Due to skilled ST, patient is now able to make
need for prn pain medicine known to nursing last
3 nights, whereas before patient could not make
needs known in this area.”
This could be part of analysis section.
52
Continued Frequency and Duration
(and intensity)
Based upon best practices
Based upon MD orders
Based upon therapist availability, but
should never be based upon therapist
convenience, or administrator’s request-
needs clinical reasoning
Should be adjusted appropriately as need
arises. May give way to partial
frequency/duration/intensity adjustments
(impacting each CPT differently, length of
treatment, etc)

(and intensity)- continued
Example for part A patient-
– A patient at a RUG score of RUC (Rehab
Ultra, extensive ADL assist) who
becomes a RUA (Rehab Ultra, low ADL
assist) is someone whom is likely ready
to RUG down soon, perhaps be weaning
down in intensity and frequency of
treatment. We need to be mindful of
this (MDS coordinator will assist with
this)
53
Impacted by ICE model of care:
– Improvable underlying impairments
may need high frequency/long duration
depending upon the co-morbidities and
extent of the deficiency in the
underlying impairment.
A patient with a knee flexion contracture of
-70 degrees with hypertonicity of
hamstrings vs.
A patient with 4/5 strength of quads
following an acute quadriceps contusion.

– Compensatory strategy instruction frequency
and duration will be dependent upon
patient/caregivers cognitive capability and
other areas of deficit.
Example- A patient with ACL 6.0 (executive level
cognition) will perhaps take just 1 treatment to learn
a compensation. One at 4.6 (early stage dementia)
will take several treatments and multiple cuing
methods.
Patients with normal cognition may be able to
compensate for significant deficits that others
cannot- such as a man with diabetic retinopathy
learning to self-administer a correct dose of insulin,
despite visual deficits making it difficult to draw up
proper amount of insulin.
54
Environmental Adaptation will generally be
of limited duration, intensity, and
frequency.
– Since it involves making environmental
adaptations, or caregiver ed (hopefully dealing
with executive level functioning caregivers),
only a few sessions should be needed to
analyze needs, make adjustments/perform
training, and arrange carryover of
training/equipment usage.
Prognosis Levels
Excellent- expected full, complete recovery.
Good- Full recovery possible, but longer than
expected due to other factors.
Fair- Improvement likely, but full recovery not
expected.
Poor- Potential to improve questionable, and
likely further regression expected.
Guarded- Patient has potential to decline to
point of needing urgent/emergent care.
Unstable- Patient unresponsive to care, declines
further after attempts.
(http://w3.palmer.edu/marriott/Docs/PROGNOSIS
%20guidelines%20v5%20(4).pdf)
55
Prognosis Levels
Gives Medicare/insurance a sense of
expectation that what they are investing is
worthwhile.
Generally, reviewers want to see a good
return on investment (expectation that
goals will be achieved)
Generally, prognosis should be Excellent
or Good.
If prognosis is Fair or less, therapy should
be fairly limited in frequency, duration,
and intensity.
Prognosis Levels - continued

How to make it always “excellent” or
“good”-
– Remember ICE?
– A patient’s potential for achieving goals (vs.
recovery) with rehab services is not dependent
just upon improvement of underlying
impairments, but also of teaching
compensatory strategies, and adapting
environment/teaching caregivers.
– A purely environmentally adaptative
intervention (such as wheelchair
prescription/fitting, or dietary modification)
can have an “excellent” prognosis, even if the
patient is completely non-participatory.
56
Prognosis Level- continued
Prognosis needs a description of why that
level was chosen.
Examples:
– “Prognosis for achieving goal is good due to
recent PLOF of total independence at home
and in community and patient’s motivation to
regain strength to tolerate prior 3-day/week
work out schedule at local YMCA. Patient also
has strong family support”
– “Prognosis is excellent due to strong patient
motivation, receptivity to careplan, and prior
compliance to ____ modifications.”
Boot Camp time- Impact on Burden

of Care, Frequency and Duration,
and Prognosis
Discussion/scenarios of impact of
burden of care, frequency and
duration, and prognosis?
57
Discharge Planning
D/C planning needs to be based
upon:
– *The patient’s failure to progress in a
reasonable and predictable time period.
– The exhausting of an individual’s scope
of practice in addressing patient needs.
– Care has become non-skilled in nature.
– D/C environment and patient/caregiver
capability to carry out maintenance.
– Use of all components of ICE.
The patient’s failure to progress in

a “reasonable and predictable” time
period
The questions to ask yourself:
– “Is the patient limited in further progression, or am I the
limiting factor?”
– “Was the patient given adequate time to progress given
complexity of the deficits and co-morbidities?”
– “If the patient will not progress, will he/she still need my
special skills?”
– “Was the focus of my goals too narrow/broad, or not
focused on the right underlying impairment(s)?”
58
The exhausting of an individual’s
scope of practice in addressing
patient needs
Have you addressed every functional
area within your SOP, and of those
areas relevant, have you assessed all
underlying impairments associated
with that area?
Do you see need for possible
referrals outside your scope? Would
these assist you in better meeting
the needs of the patient?
Care has become non-skilled in

nature
Is care becoming repetitive?
Does care really require special
skills?
Could patient progress with non-
skilled interventions?
59
D/C environment and
patient/caregiver capability to carry
out maintenance
Is patient changing current living
environment that will eliminate need
for interventions?
Has patient/caregiver taken over
some/all aspects of care?
Is patient expected to maintain at
current level of function or better on
a maintenance program?
Use of all components of ICE

Were all impairments improved to their
fullest capability?
Did the patient learn all available
compensatory strategies, and is no longer
capable of progressing in this area?
Have I modified the patient’s environment
and trained all applicable caregivers to
prevent regression, or allow continued
improvement?
60
Another component of the D/C
summary…
Proving your worth-
– Discussion of skilled interventions from
SOC to D/C- a sales pitch at the end of
the encounter, like the RFR was at the
beginning. (Same criteria as explaining
skilled services previously, with focus on
progressions)
– Review of impact of therapy upon the
patient’s functional state/burden of
further care.
D/C Boot Camp

Find your discipline specific d/c
summary that has only had the
change in function and CPTs billed
documented, and write analysis,
skilled interventions, etc. You may
work as teams or individually.
61
Functional Limitation Scoring (G
codes)
Functional Limitations reporting does
not impact reimbursement due to
performance improvement of
scores…
…however, failure to report G codes
with Part B and Part B like
insurances will prevent billing of
services.
Functional Limitation Codes

Since January 1, 2013, the Centers for
Medicare and Medicaid Services (CMS) has
been required by the Middle Class Tax
Relief Act of 2012 to collect information
from outpatient therapy settings regarding
beneficiaries’ function and condition,
therapy services furnished, and outcomes
achieved on patient function. CMS
intends to use this information to
reform payment for outpatient
therapy services.
(http://scapta.org/files/documents/Functi
onalLimitationReportingToolkit.pdf)
62
Functional G codes- continued
When do we provide functional G
codes?
The initial evaluation or onset of Part B
coverage- even evaluations only
Each therapist progress note (every 10
treatment sessions)
Each Updated Plan of Care or re-evaluation
Each time there is a change in G-code
functional category
Each discharge summary
Done by a therapist, on the day of Rx
Functional G codes - continued
We must also document the specific

functional assessment(s) used in
determining the severity modifier, and use
that same functional assessment(s) for
each reporting point.
Each time you report, you must use same
standardized, objective testing.
Testing of one category at a time,
consistent with LTG(s)
See “Functional G Code Categories”
handout
63
Functional G codes- continued
Severity modifiers
– CH = 0% impaired, limited or restricted
– CI = At least 1% but less than 20% impaired,
limited or restricted
– CJ = At least 20% but less than 40% impaired,
limited or restricted
– CK = At least 40% but less than 60%
impaired, limited or restricted
– CL = At least 60% but less than 80%
– CM = At least 80% but less than 100%
– CN = 100% impaired, limited or restricted
So, how should you determine a g- code?
There is really a rather vague instruction

on this by CMS:
– “The therapist must document how the
modifier selection was made (E.G., through
use of one functional assessment tool; use of
more than one tool; or use of clinical judgment
to determine the modifier).”
(http://web.missouri.edu/~proste/reimbursem
ent/reimbursement/ReportingPatientFunctionto
Medicare-WebinarSlides.pdf)
– This could (at this time) mean practically
any standardized assessment- the key is
simply being consistent from report to
report.
64
Examples of G code modifiers
resources
http://www.mediserve.com/resource/analysis/cb
or-conversion/ (example of app available)
http://web.missouri.edu/~proste/reimbursement
/reimbursement/ReportingPatientFunctiontoMedic
are-WebinarSlides.pdf- offers some detailed
information
Short and long descriptors of G codes:
https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/G-Codes-Chart-
908924.pdf
Logic of grading G codes…

Examples:
– A patient requires min physical assist to
ambulate (25% assist), 100% verbal cues for
safe technique. The average between the 2
could be taken to give the severity modifier:
55% avg, meaning severity modifier of –CK
– A patient chokes on 1/10 attempts at ¼ tsp of
thin liquids. The severity modifier is –CI
– A patient scores 4.8 on the ACL. The patient
needs 50% assist to use a list of 3 instructions
to carry out morning ADLs. There are 28
modes of Allen levels, 4.8 correlates with
21/28, which would be 25% limited, which
would mean average of 37.5%, again meaning
a –CJ. The OT chose the “memory” category.
65
Bottom line on G codes
The actual severity modifier does not now impact
reimburement, just collection of data.
The G codes with severity modifier can be
determined fairly simply through standardized
tests, or combination thereof.
Combining assessments, or using complex
standardized tests, may be the best way to get
an accurate G code severity modifier, which could
have significant impact on G code reporting in
future should (when) Medicare use(s) it to
determine reimbursement.
Putting it all together…

A proper RFR is formed from 3
components, with a 4th helpful…
– The relationship of the medical and treatment
diagnosis
– A brief summary of the functional deficits and
the underlying impairments that cause them
– A statement of medical necessity
– If possible, any relevant co-morbities that will
impact care
Functional Deficits (seen by everyone) are
caused by Underlying Impairments
(determined by skilled assessment)
66
Putting it all together…(continued)
Goals should have both a functional
component and underlying
impairment component, and follow
SMART format.
CPT codes are determined by the
objective functional and underlying
impairments assessed.
Prognosis is based upon all aspects
of the ICE model of care.

Frequency and duration (and
intensity) are determined by…
– ICE model of care
– D/C environment
– PLOF
– Co-morbidities/medical stability
– Cognition
67
Progress notes should show the following:
– A change in function, or explanation as to why
no change
– A solid analysis of the change/lack of, based
upon objective FD and UI in goals
– A thorough explanation of skilled services,
detailing each one of the CPT codes
– A therapy impact on burden of care
– A prognosis based upon goal completion
capability, not necessarily patient medical
status/ability to restore only.

A D/C summary should:
– Contain what a progress note contains
– Contain a summary of skilled services from
SOC to D/C
– Contain an analysis that makes it clear that
the therapist’s SOP has been exhausted to
address all patient needs, unless another
reason than therapist decision has caused
discharge.
– Should be completed when care has become
non-skilled.
68
Questions???????
Thank you for being so attentive and
participating in boot-camp- you are
now ready to face anything Medicare
throws at you!
(Applause, kudos, and dark chocolate

all appreciated!)
69
CASE STUDY #1/BOOT CAMP EXERCISE 1
Patient John Doe is a 67 y/o male with h/o CAD, PVD, a-fib, and DM type 2, controlled
by oral meds. Two weeks ago, patient suffered a left CVA with right hemi, and while in
hospital was also found to have a blood sugar of 240 approximately 2 hours post-
prandial. He presents with the following deficits.
Right UE strength of 3+/5 shoulder, 2+/5 at elbow, and 1+/5 hand; Right knee extension
3-/5, ankle DF 2+/5.
Cannot feed self
Keeps repeating “there” for every response to any question
Slightly hypertonic right LE rated at 2/4 on modified Ashworth scale
Bed mobility with min assist to left rolling, verbal and tactile cuing to right
Chews and chews food but never seems to clear mouth completely, drools
Transfers without locking brakes
7/28 Tinetti balance score
Ambulates with moderate assist of 1, lefts right leg and flops in forward, wide BOS
Incomplete labial closure and pocketing of food right side of mouth with inability to
detect, needing cues for sweeping right sulcus
Gets frustrated easily when nurse comes to give him meds, spits out pills
Bilateral LE hair loss, thickening of nails, hemosyderin deposits mid calf bilaterally
Severe global aphasia noted
70
BOOT CAMP EXERCISE 2a: WRITING THE REASON FOR REFERRAL
Take the following information and use it to write a discipline specific RFR. Remember
the elements:
1) treatment and medical diagnosis are contained and related in the RFR
2) there is a brief summary of the functional deficits and the underlying impairments
that cause them.
3) There is a statement of medical necessity.
4) If relevant, there is a statement concerning co-morbidities that will impact care.
Medical dx: UTI, septicemia with 10 day acute hospital stay
Functional deficits:
Safety issues with getting up from chair repeatedly
Decreased memory, patient getting lost trying to find room
Not getting self dressed, needing cues and supervision to complete grooming
Started wetting self during day, but generally dry at night
Unable to transfer without significant assist, cuing, non-ambulatory
Underlying Impairments:
Oriented x 1
Severely impaired safety/judgment
1 minute attention span
DOE with any out of bed activity, RR 22 at rest, 30-35 with bed mobility, attempting
transfers, and any ADLs
Cannot manage clothing/fasteners
71
BOOT CAMP EXERCISE 2b: WRITING THE REASON FOR REFERRAL
Med dx: PT and OT= CELLULITIS OF LEG

ST= CVA
Treatment dx: PT and OT= MUSCLE WEAKNESS

ST= SYMBOLIC DYSFUNCTION NOS
Recent medical hx: 94 y/o female 9/28 to 10/9 admit due to cellulitis and suspected CVA 3
weeks prior to hospital admit. PMH includes Hypothyroidism. Hypertension. Anemia.
Hypoalbuminemia. Osteopenia. Chronic LE edema (08/2013).
Functional deficits PT:

Transfers: max A x 2
Gait: unable to ambulate
Bed mob: rolling mod A, Sit <> supine max A
Underlying Impairments PT:

Sitting balance/static: F- (maintains with bilateral UE support)
Sitting balance/dynamic: F- (able to weight shift with UE support, requires min assist to
reach ipsilaterally)
Strength: bilateral hips 2/5, knees 3/5, ankles 3/5
O2 sats: 92-94% at rest/with activity
Edema: 1+ pitting bilateral LE mid-calf to below
Functional Deficits OT:

UB dressing and bathing: max A
LB dressing and bathing: max A
Toilet management (includes transfers): max A
Underlying Impairments OT:

UE strength: 3/5 bilaterally
Sitting balance: 1/5 Kansas University Balance Assessment (supports self with UEs but
requires therapist assist to maintain balance)
Cardio-pulmonary: Rate of Perceived Exertion (RPE/modified Borg) 2/10 at rest, 6/10
with attempts at sitting EOB performing ADLs, requiring rest approx Q 2 minutes.
Functional Deficits ST:

Cognition A&O x 4
No swallow deficit, on mech soft/ground diet with thin liquids (was previously on regular
consistency)
Able to complete 75% of functional tasks with cuing
Good attention
72
BOOT CAMP EXERCISE 2b: WRITING THE REASON FOR REFERRAL- part 2
Underlying Impairments ST:

Cognitive performance assessment: ACL of 3.6 (needs 24 hour supervision, can learn
new activity in consistent training over 3 weeks, manipulates objects, may demonstrate
behaviors)
IND attention, receptive language skills
7 on FOIS
Complete dentition
No coughing with presentation
Normal face symmetry
Normal A-P transit
73
OT goal practice sheet
Reason For Referral: Patient is a ___ y/o female with h/o recent left LE cellulitis, and
CVA who presents to OT with significant decline in all ADL/functional areas due to
prolonged bed rest and weakness of bilateral UE, as well as decreased sitting balance
and increased perceived exertion. Without skilled OT, patient will remain more greatly
dependent upon caregivers for all aspects of care, decreased activity tolerance, at
increased risk for falls, greater assistance needed in positioning of self to reduce risk of
skin breakdown and failure to return to PLOF.
Medical History Related to Diagnosis/Condition: Hypothyroidism. Hypertension. Anemia.

Hypoalbuminemia. Osteopenia. Chronic LE edema (08/2013). Depression. C-Diff.
Macular degeneration , OA.
Prior Residence and Living Arrangement: Pt has been a LTC resident of this SNF since
2008. Pt is independent with W/C mobility around the facility and ambulates with
caregiver assist using RW. Pt requires min assist for all ADLs, and transfers to toilet with
.
CLOF:
UB & LB bathing and Dressing: max A
Toilet hygiene: max A
Toilet transfers: max A, caregivers are using sara lift
Bilateral UE gross strength: 3-/5

Seated balance: Fair – static (requires use of 1 arm to maintain sitting or will lose balance)
RPE 6/10 with 2 rests needed during attempts at any seated or supine ADLs
74
Goal Practice Time Worksheet- PT
Reason For Referral: Patient is a 74 y/o female with h/o chronic LE edema who
developed cellulitis of the left LE and was hospitalized on 9/28/13. Patient is also
suspected of having right CVA approximately 3 weeks prior to hospitalization. Due to
prolonged bed immobility and effects of CVA, patient demonstrates significant muscle
weakness. Upon assessment, patient demonstrates significant decline in mobility in all
areas due to weakness, decreased balance, and decreased O2 saturation. Without
skilled PT, patient will be at high risk for falls with injury, dependency on caregivers,
failure to return to PLOF, and decreased quality of life.
Medical History Related to Diagnosis/Condition: Hypothyroidism. Hypertension. Anemia.

Hypoalbuminemia. Osteopenia. Chronic LE edema (08/2013). Depression. C-Diff,
macular degeneration, OA.
Prior Residence and Living Arrangement: Pt has been a LTC resident of this SNF since
2008. Pt is independent with W/C mobility around the facility and ambulates with
caregiver assist using RW. Pt requires assistance to transfer.
CLOF:
Bed mobility is max assist for sit<>supine, rolling left mod IND, right mod A
Transfers sit<>stand with mod assist, stand-pivot transfers with max A
Gait – amb in rolling walker with max A x 10 ft
Right LE strength grossly 4/5, left 3-/5, abs 3-/5
Left ankle DF ROM 5 degrees with knee in extension
Rolls left LE into ER, slight genu-recurvatum during stance
Tinetti balance score 7/28
Resting O2 sats 94%, after ambulation 85%
75
Goal Practice Time worksheet- ST
Reason for referral:

Patient is a 72 y/o female with h/o Alzheimer’s dementia, previous h/o associated oral
phase dysphagia, who was placed on a mechanical soft diet with thin liquids
approximately 1 year ago. Patient also has loss of dentition. A family member noted
approximately 1 week ago that the patient was pocketing food and was chewing
constantly the same mouthful, with occasional spitting food out and drooling, and was
having to be cued to swallow every bite, but despite this patient was only completing
approximately ¼ meal in 1 hour, which indicates inadequate nutrition to maintain
patient’s current body weight. The patient has also been noted to have coughing with
thin liquids on several occasions.
Therapy assessment reveals significant swallowing issues related to oral phase of
swallow, impacted by patient’s poor dentition, lack of bolus cohesion, decreased A-P
transit, pocketing of food, and intolerance to certain food textures. Patient is also noted
to have problems with use of straw and thin liquid swallow, indicating a component of
requiring pre-oral cuing to safely swallow liquids.
Without skilled speech therapy, patient is at significant risk of aspiration, with associated
complications including potentially death.
PMH: Alzheimer’s, oral dysphagia, CAD, PVD
Functional deficits:
Significant oral phase dysphagia
Underlying impairments:
Most teeth missing- patient had dentures but is unwilling to wear due to discomfort
A-P transit- approximately 4 seconds
Reduced buccal tension/tone
Tongue ROM/strength- moderately impaired
Slight tongue residue noted
Attention span- approximately 1 minute
Orientation- x 1
76
Change in Function- Examples
ST
Goals PLOF CLOF
Pt. will comprehend word Pt. comprehends familiar Pt. comprehends word
length information at 90% word length information at length information at 80%
accuracy in order to express 50% accuracy, requiring accuracy, with ability to
simple wants or needs, such moderate cuing and make need for toileting
as requesting pain meds and caregiver interviewing to known, but requires
need for using toilet. determine need for pain caregiver to interview
meds or need to void. concerning pain control
needs.
Pt will exhibit improved Pt exhibit diminished Pt exhibits improved
strength and coordination of strength and coordination of strength and coordination of
oropharynx and swallow oropharynx and swallow oropharynx and swallow
function as evidenced by 1 function as evidenced by 5 function as evidenced by 0
or fewer incidences of incidences of coughing or incidents of coughing or
coughing or choking on choking on secretions in a choking on secretions in the
secretions in one week. one week period. past week.
OT
Goals PLOF CLOF
The patient will report Patient has right shoulder - Patient reports being able to
decreased right shoulder neck pain rated at 7/10 do/doff shirt with 5/10 pain,
pain, rated at less than 3/10 when attempting above but requires NSAID to calm
in order to allow patient to shoulder level activity, pain afterwards, and reports
don/doff pull-over shirts limiting him to button down sleeping through night 4 of
IND and sleep through shirts only, and patient last 7 nights without
night without awakening reports awakening awakening .
due to pain. approximately every other
night with pain in shoulder
that requires use of pain
meds to get back to sleep.
Patient will complete basic Patient requires Min-mod Patient requires CGA-min
self care tasks with SBA assist with seated EOB A for seated EOB grooming
seated edge of bed due to grooming activities due to tasks due to seated balance
balance of Fair+ Poor+ dynamic balance. of Fair.
dynamically in sitting, to
progress patient towards
IND with morning ADLs .
The patient will The patient is unable to Patient sits up in chair for
demonstrate ability to tolerate being in chair for one hour before needing
tolerate 2 hours seated in greater than 30 minutes repositioning due to sliding
wheelchair due to proper with caregiver set-up, and is in chair. Patient is not
77
set-up of positioning noted to have excessive keeping right forearm
devices by caregivers to posterior pelvic tilting, loaded, slouches right and
provide normal seated sliding forward in chair, thrusts out left hip during
alignment at 90/90/90 and thereby limiting ability of sitting greater than 45
appropriate forearm patient to have time up for minutes to 1 hour. Patient
loading. activities without significant unable to self correct with
caregiver intervention. cuing.
Change in Function- Examples
PT
Goals PLOF CLOF
Patient will improve cardio- Patient exhibits cardio- Patient exhibits a perceived
pulmonary capacity as pulmonary limitations as exertion of 5/10 (heavy
exhibited by achieving Borg evidenced by Borg Scale of exertion) after ambulating
Scale of PE: 3 moderate PE: 7 very heavy exertion, 15 ft, with one minute rest
exertion , after ambulating and requires rest of 5 break to continue with
25', to allow patient ability minutes after attempting to further activity.
to go from bed to bathroom. ambulate 10 ft, which does
not cover any functional
distance.
The patient will improve The patient demonstrates The patient demonstrates
gross muscle strength to 5,5 gross muscle strength of gross muscle strength of 5-
in order to ambulate and 4+,5 , impacting need for /5 , impacting need for SBA
transfer with SBA SGA - CGA for gait and with gait and transfers.
transfers
Patient will demonstrate Berg 36/56, requiring CGA- Berg score 40/56, requiring
Berg balance score of min assist on level with SBA for ambulation with
>=45/56 to allow FWW, RLA dyspnea of 3+ walker with slight
ambulation with FW walker necessitating 1-2 rest breaks retropulsion during turns
on level surfaces mod IND, of >=3 minutes to complete with supervised recovery,
and RLA dyspnea of <=2+ 300 ft ambulation. and RLA 2+ during
to allow ambulation >=300 ambulation, but patient self-
ft to access community pacing with one rest break
without risk of cardio- at 200 ft for 1 minute before
pulmonary decompensation. completing another 100ft.
78
Skilled Analysis Boot Camp
PT
Goals PLOF CLOF
Patient will improve cardio- Patient exhibits cardio- Patient exhibits cardio-
pulmonary capacity as pulmonary limitations as pulmonary limitations as
exhibited by achieving Borg evidenced by Borg Scale of evidenced by Borg Scale of
Scale of PE: 1 Very slight PE: 5 severe exertion , PE: 2 Slight breathlessness ,
breathlessness , in order to impacting toleration of impacting ability to
ambulate 100ft with AD to ambulation up to 80ft . ambulate up to 100ft with
go from bedroom to dining FWW .
room .
The patient will report Patient reports c/o of in left Patient reports 3-4/10 night-
decreased left hip and lower hip rated 5-6/10 at night, time pain, has slept through
back pain, rated at no pain, awakening patient on avg 1- night 2/7 nights this week,
to allow patient to sleep 2 times per night. Patient still requiring prn pain meds
through night without requests prn pain meds on nights that he awakes.
awakening due to pain and QHS.
requesting pain meds .
Patient will have a The patient scored 13/28 on Tinetti score of 17/28,
functional balance Tinetti balance assessment, continued high fall risk, but
improvement to Tinetti placing at high fall risk, and now allowing patient to
score of >=20/28 to reduce necessitating CGA- ambulate with SBA.
fall risk and allow amb with occasional min assist to
FWW in level IND maintain balance during
gait./
Skilled Analysis:
79
OT
Goals PLOF CLOF
Pt will dress upper body Pt. dresses upper body with Pt. dresses upper body with
with Supervision and lower Minimal Physical SBA and lower body with
body with Minimal Physical Assistance and lower body Standby Assistance due to
Assistance, due to seated with Moderate Physical seated balance of Good -.
balance of Fair + Assistance, due to seated
dynamically. balance of Fair .
The patient will report Patient has left shoulder Patient has L shoulder pain
decreased left shoulder pain rated at moderate- rated at moderate pain
pain, rated at mild pain in severe pain impacting need impacting need for rest after
order to propel wheelchair for min assist to complete completion of 40 ft
throughout facility without wheelchair mobility x 25 ft, propulsion, requiring 3 rest
exacerbation of sx. allowing patient to breaks to get from room <>
complete bed<>bathroom . activities dept and dining
Patient unable to utilize feet room.
in propulsion.
The patient will improve The patient demonstrates The patient demonstrates R
muscle strength to 4+/5 in B RUE strength of 4/5 and UE muscle strength of 4/5
UE in order to propel LUE strength of 3+/5 And LUE strength of 4-/5
wheelchair with distant impacting need for min impacting ability to propel x
supervision, without assist to propel wheelchair x 40 ft.
fatiguing, x 150 ft to<>from 25 ft
dining room.
The patient will The patient does not stop The patient demonstrates
demonstrate ability to self- activity IND 3/5 trials, and ability to self-pace activity
pace activity to prevent pain reaches level of mod-severe 5/5 trials to prevent pain
level from rising above mild pain levels left shoulder, arising >moderate, with
in left shoulder. necessitating long rest approximately 1 minute rest
breaks to alleviate break to alleviate sx after
exacerbation . activity.
Skilled Analysis:
80
ST
The patient will improve The patient hums along The patient hums along
participation in production with SLP production of with SLP for production of
of automatic speech to automatic speech with automatic speech with
MODERATE (70-74% MODERATE (60-64% MODERATE (50-54%
accuracy) impairment, accuracy) impairment. She accuracy) impairment. She
requiring verbal, visual and has not verbalized does not verbalize at this
tactile cueing in order to automatic phrases at this time although she is
increase verbal expression. time. It appears she is participating.
attempting.
The patient will improve The patient demonstrates The patient demonstrates
ability to follow simple 1 ability to follow 1 step ability to follow 1 step
step directions to 65% directions limited to 50% directions limited to 35%
accuracy requiring verbal, accuracy, requiring verbal, accuracy, requiring verbal,
visual and tactile cueing . visual and tactile cueing . visual and tactile cueing .
The patient will respond to The patient responds to The patient responds to
yes/no questions with 75% yes/no questions with 45% yes/no questions with 65%
accuracy requiring visual accuracy, requiring visual accuracy, requiring visual
and verbal cueing to and verbal cues. Patient and verbal cueing .
increase appropriate needs multiple attempts by Caregivers demonstrate
functional communication, caregiver to determine IND with allowing patient
such as answering if need to needs, resulting in several extra time to respond to
use restroom. attempts by patient to arise yes/no questions, and
from chair and one fall this patient has not had fall in
past week due to patient last 2 weeks.
inability to express need for
toilet.
Patient will imitate oral Patient imitate oral postures Patient imitate oral postures
postures with 50% accuracy with 35% accuracy with with 25% accuracy with
with verbal, visual and verbal and visual cues for verbal, visual and tactile
tactile cues for oral motor oral motor retraining for cues for oral motor
retraining for verbal verbal communication. retraining for verbal
communication. communication.
Skilled Analysis:
81
D/C Summary Practice
ST
ST Goal(s) Goal Prior Level of Function 5/9/2013 Current level of Function Goal Date
Communicate **GOAL MET - DC'd on Patient communicates basic **GOAL MET - DC'd on 05/21/2013
5/23/2013** Pt. Will effectively wants/needs with 85-90% accuracy 5/23/2013** Patient communicates
communicate basic wants/needs via requiring minimal verbal cuing and basic wants/needs with 90%
single word response with 90% occasional repetition of simple accuracy requiring minimal verbal
accuracy requiring minimal verbal yes/no question via communicative cuing and inconsistent repetition of
cuing and inconsistent repetition of partner. simple yes/no questions via
simple yes/no questions via communicative partner.
communicative partner.
MS - Oral Motor **GOAL MET - DC'd on Patient's oral motor **GOAL MET - DC'd on 05/21/2013
(Strength, ROM, 5/23/2013** Patient will increase strength/ROM/coordination is 5/23/2013** Patient's oral motor
Coordination) oral motor limited to 80-85% accuracy, strength/ROM/coordination is
strength/ROM/coordination to 85- impacting ability to manipulate, limited to 85-90% accuracy,
90% accuracy, in order to masticate, and propel pureed and impacting ability to manipulate;
manipulate, masticate, and propel honey thick liquids safely and masticate; and propel pureed and
pureed and honey liquids safely and effectively. honey thick liquids safely and
effectively. effectively.
SW-Ability to **GOAL MET - DC'd on The patient safely swallows small **GOAL MET - DC'd on 05/21/2013
Swallow (liquids) 5/23/2013** The patient will safely sip via nosey cup using 5/23/2013** The patient safely
swallow small sip via cup of Honey compensatory strategies from SLP swallows small sip via nosey cup
thick liquid using compensatory and/or trained staff requiring 30- using compensatory strategies from
strategies from SLP and/or trained 35% tactile and verbal SLP and/or trained staff requiring
CNA staff requiring 20-35% verbal instruction/cues and manual 20-30% verbal instruction/cues and
instruction/cues and feeding assistance in a supervised dining and feeding assistance in a
assistance in a supervised dining room setting. supervised dining room setting.
room setting.
82
SW-Ability To **GOAL MET - DC'd on The patient demonstrates ability to **GOAL MET - DC'd on 05/21/2013
Swallow (solids) 5/23/2013** The patient will safely safely swallow 1/2 - 2/3 teaspoon of 5/23/2013** The patient
swallow 1/2 - 2/3 teaspoon of puree puree diet using compensatory demonstrates ability to safely
diet using compensatory strategies strategies from SLP requiring 10- swallow 1/2 - 2/3 teaspoon of puree
from SLP and/or trained CNA staff 15% verbal instruction/cues and diet using learned compensatory
requiring minimal verbal manual feeding assistance in a strategies requiring minimal verbal
instruction/cues and feeding supervised dining room setting. instruction/cues and feeding
assistance in a supervised dining assistance in a supervised dining
room setting. room setting.
SW-Safe Swallow **GOAL MET - DC'd on Caregivers/Staff require 20-30% **GOAL MET - DC'd on 05/21/2013
(Staff) 5/23/2013** Caregivers/Staff will be verbal cueing to effectively cue 5/23/2013** Caregivers/Staff
independent in usage of patient patient to utilize swallow require no cues to effectively cue
specific safe feeding strategies. strategies/precautions. patient to utilize swallow
strategies/precautions.
LT Goal(s)
Patient will safely tolerate a puree diet and HONEY thick liquids effectively utilizing compensatory strategies 90-100% of the time without overt
signs/symptoms of aspiration to optimize hydration and nutrition.
CPT Codes Provided Since Last Report:

92507 - Treatment of speech, language, voice
92526 - Treatment of swallowing dysfunction and/or oral function for feeding
Analysis of Functional Outcome / Clinical Impression:
Skilled Services Provided Since Last Report:
83
Patient / Caregiver Training: Caregivers able to demonstrate appropriate usage of patient specific safe feeding strategies with 100%
competency. Patient should be upright in wheel chair for all meal consumption; patient should be fed in a supervised dining room
setting; patient should be fed slowly; should be fed via 1/2 - 2/3 teaspoon per presentation; should consume all liquids via small sip per
presentation; diet and liquids should be alternated during feeding process; patient should be allowed sufficient time to orally manipulate
and propel each bolus; and patient should remain upright 30 minutes following each meal secondary to hx of GERD.
Summary of Skilled Services Provided since SOC:
Impact on Burden of Care / Daily Life:
Precautions: ASK YES/NO QUESTIONS TO COMMUNICATE. POSITION AT 90 DEGREE ANGLE DURING AND 30 MINUTES
AFTER ORAL INTAKE SECONDARY TO HIS H/O GERD. PATIENT IS PRESENTLY ON A PUREED DIET AND HONEY THICK
LIQUIDS; NO STRAWS. ASPIRATION RISK; FALL RISK; DYSARTHRIA.
Discharge Plans: DISCHARGE FROM SKILLED DYSPHAGIA TX EFFECTIVE 5/23/13. PATIENT TO REMAIN ON A PUREED DIET
TEXTURE WITH HONEY THICKENED LIQUIDS. PATIENT SHOULD CONSUME ALL MEALS IN SUPERVISED DINING ROOM
SETTING AND SHOULD BE FED BY TRAINED CNA STAFF.
84
OT
ST Goal(s) Goal Prior Level of Function 12/23/2013 Current level of Function Goal Date
Pain The patient will report decreased Patient has right shoulder, left Patient has right shoulder, left 12/24/2013
bilateral shoulder and lower back shoulder and lower back pain rated shoulder and lower back pain rated
pain, rated at 1 out of 10 in order to at 2/10, 4/10 and 3/10 impacting at 1 out of 10 and
perform supine to sit and sit to stand need for Modified Independence as occasional/intermittent impacting
transitions with complete exhibited per extra time to transition need for to .
independence . from supine to sit and sit to stand .
Strength: Shoulder The patient will increase B UE The patient demonstrates B UE gross The patient demonstrates B UE gross 12/24/2013
muscle strength to 4/5 and grip muscle strength of 3+/5 also right muscle strength of 4/5 also right
strength to =/> right hand 45 and left hand grip 42 psi avg and left hand 40 hand grip 45 psi avg and left hand 40
40 psi avg in order to reach and psi avg impacting need for MOD (I) psi avg impacting need for complete
grasp supplies/items with complete to reach and grasp supplies/items. independence to reach and grasp
independence . supplies/items.
LT Goal(s)
The patient will report decreased bilateral shoulders and lower back pain, rated at occasional or intermittent pain in order to return to PLOF including
leisure activities with Moderate Cognitive Assistance and no physical assistance.

97024 - Diathermy
97110 - Therapeutic exercise
G0283 - Electrical stimulation, (Supervised), to one or more areas, other than wound care
85
Patient / Caregiver Training: Restorative nurse instructed to complete pain management and strengthening of BUE programs.
Summary of Skilled Services Provided since SOC: The skilled teaching and training provided to the patient and caregiver over this
course of therapy treatment included pain management allowing transition of care from therapy to the patient and staff.
Precautions: Lower back and bilateral shoulders chronic pain. Unsteady gait.
Discharge Plans: Patient to discharge from skilled OT with restorative program to address lower back pain.
86
PT
Goal(s) Goal Prior Level of Function 9/20/2013 Current level of Function Goal Date
Bed Mobility- The patient will safely roll from side The patient is able to roll from side The patient is able to roll from side 09/17/2013
Rolling to side with CGA and use of siderail/ to side requiring MAX assist . to side requiring CGA .
trapeze bar .
Bed Mobility- The patient will safely transition The patient transitions from supine The patient transitions from supine 09/17/2013
Supine<> Sit from supine <> sitting position with <> sitting position requiring MAX <> sitting position requiring MOD
MOD assist to decrease burden of assist . assist of (2) .
care during ADL's and transfers. .
Sitting Balance: The patient will have functional The patient scored 3,5 on the Kansas The patient scored 3,5 on the Kansas 09/17/2013
Kansas Univ Scale 1 balance improvement to 3+,5 on the Univ Sitting Balance Scale to . Univ Sitting Balance Scale .
Kansas Univ Sitting Balance Scale,
in order to decrease risk of falls
while sitting up in w/c.
Wheelchair Mobility: **GOAL MET - DC'd on The patient currently propels **GOAL MET - DC'd on 09/17/2013
Distance 9/7/2013** The patient will wheelchair 50 feet . 9/7/2013** The patient currently
efficiently and safely propel propels wheelchair 50 feet using
wheelchair 50 feet on level surfaces BUE requiring extra time and SBA .
using B UE with intermittent MIN
assist to increase independence in
environment.
LT Goal(s)
Pt will complete rolling in bed with SBA and use of siderails, trapeze bar to help improve ability to reposition in bed .
The patient will efficiently and safely propel wheelchair 100 feet using B UE with Supervision to increase independence in environment.
87
97110 - Therapeutic exercise
97112 - Neuromuscular re-ed
97530 - Therapeutic activities
97542 - Wheelchair management
Patient / Caregiver Training: Caregivers were able to provide required assistance with positioning in bed and wheelchair with complete
independence. Restorative nurses trained to execute planned functional maintenance program for the patient
Summary of Skilled Services Provided since SOC: Pt performed Therapeutic exercises including FTF exercises, omni bicycle, Range of
motion exercises with B/L LE, core strengthening exercises and back strengthening exercises Pt caregiver education and training on
providing required assistance and positioning in bed and wheelchair
Precautions: falls, B AKA, pacemaker, dialysis M-W-F, dialysis shunt L UE, seatbelt in w/c.
Discharge Plans: Pt d/c to same SNF : LTC
88
89
Resident Rights: OBRA law impact on identifying patient needs for therapy
The resident has a right to a dignified existence, self-determination, communication

with and access to persons and services inside and outside the facility.
The resident has a right to exercise his or her rights as a resident of the facility as a
citizen or resident of the United States.
The resident has the right to be fully informed, in a language he or she can understand,
of his or her total health status, including but not limited to his or her medical condition.
The resident has the right to refuse treatment and to refuse to participate in experimental
research.
The resident has the right to exercise his or her legal rights, including filing a grievance
with the state survey and certification agency concerning resident abuse, neglect, and
misappropriation of resident property in the facility.
The resident has the right to manage his or her financial affairs.
The resident has a right to participate in planning his or her care and treatment or
changes in care and treatment unless judged incompetent or otherwise found to be
incapacitated under the laws of the state.
The resident has a right to voice grievances with respect to treatment or care that fails
to be furnished, without discrimination or reprisal for voicing grievances.
The resident has a right to perform voluntary or paid services for this facility if he or
she desires, if there is no medical reason which would contradict the performing
of the services, and if compensation for the services is at or above prevailing
rates.
The resident has a right to privacy in written communications, including the right to send
and receive mail promptly that is unopened. The resident has a right of access to
stationery, postage, and writing implements at the resident’s own expense.
90
The resident has a right to have reasonable access to the private use of a telephone.
The resident has a right to retain and use personal possessions, including some
furnishings and appropriate clothing as space permits, unless to do so would
infringe on the rights or health and safety of other residents.
Each resident has a right to self-administer drugs unless the facility interdisciplinary
team has determined for a particular resident that this practice is unsafe.
The resident has the right to be free from any physical restraints imposed or
psychoactive drugs administered for the purposes of discipline or convenience, and
not required to treat the resident’s medical symptoms.
The resident has a right to choose activities schedules and health care consistent with
his or her interests, assessments, and plans of care.
The resident has a right to organize and participate in resident groups in the facility,
and the resident’s family has the right to meet with families of other residents.
The resident has a right to participate in social, religious, and community activities
that do not interfere with the rights of other residents.
91
G Code Functional Categories
Physical Therapy Occupational Therapy Speech Therapy

Mobility: Walking & Moving Around Mobility: Walking & Moving Around Swallow
Changing & Maintaining Body Changing & Maintaining Body Motor Speech
Position Position Spoken Language Comprehension
Carrying, Moving and Handling Carrying, Moving and Handling Spoken Language Expression
Objects Objects Attention
Self Care Self Care Memory
Other PT/OT Primary Attention Voice
Other PT/OT Subsequent Memory Other SLP
Swallowing
Other PT/OT Primary
Other PT/OT Subsequent
Each code has a specific number sequence with a severity code based upon % of disability chosen.
Severity Modifiers:
 CH = 0% impaired, limited or restricted

 CI = At least 1% but less than 20% impaired, limited or restricted
 CJ = At least 20% but less than 40% impaired, limited or restricted
 CK = At least 40% but less than 60% impaired, limited or restricted
 CL = At least 60% but less than 80% impaired, limited or restricted
 CM = At least 80% but less than 100% impaired, limited or restricted
CN = 100% impaired, limited or restricted
92
Documentation Bootcamp Reference Page:
www.cms.gov
Medicare Claims Processing Manual Chapter 5 - Part B Outpatient Rehabilitation and CORF /
OPT Services. (2015, March 16). Retrieved August 21, 2015, from
https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/clm104c05.pdf
Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under
Hospital Insurance. (2015, March 13). Retrieved August 21, 2015, from
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c08.pdf
Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services.
(2015, February 13). Retrieved August 21, 2015, from
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
CMS Manual System PUB 100-02 Medicare Benefit Policy Transmittal 88. (2008, May 7).
Retrieved August 21, 2015, from https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/downloads/r88bp.pdf
https://www.cms.gov/Medicare/Medicare-Fee-for-
ServicePayment/SNFPPS/Downloads/Jimmo-FactSheet.pdf
www.rehabmeasures.org
http://practiceperfectemr.com/us/wp-content/uploads/PQRS-CheatSheet-PTOT.pdf
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-
MLN/MLNProducts/Downloads/G-Codes-Chart-908924.pdf
93
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service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.
© Copyright 2014 John Adamson, PT, M.Div., GCS & Summit Professional Education. No part of this workbook may be reproduced in any
manner without the expressed written consent of John Adamson, PT, M.Div., GCS and Summit Professional Education.
From a Declaration of Principles jointly adopted by a committee of the American Bar Association and a committee of Publishers.

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Your Top Choice in Continuing Education

Documentation Bootcamp for

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-The Summit Team

Phone: (800) 433-9570

About Today’s Instructor

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The Rehab Documentation Guru- YouTube channel

Cost of Medicare vs. Inflation

Costof living in 1966 compared to

Medicare B cost control

RAC (Recovery Audit Contractors) has recovered

Where that leaves us…

–medical necessity exists…

Un-“Skilled” services are…

Proving Skilled Necessity of Care

Professional Advocacy Groups

Functional Deficits vs. Underlying

Observable by all people

Functional Deficits and Underlying

Functional Deficits and Underlying

Medical and Treatment Dx

Medical and Treatment Dx

Therefore, please describe the complexity of the patient

Reason for Referral (RFR)

And one for Speech…

Relating the medical and treatment

Writing a strong RFR (continued)

Writing a strong RFR (continued)

Boot Camp exercise #2

Goal Writing- SMART goals

– Some MACs are requiring STGs, even though

What should not be in the goal

Highest level attainable

Examples of weak goals

ICE model of care- application to

ICE model of care- application to

Use of MDS (Minimal Data Set)

Use of MDS data for functional

One more thing about goals…

Choosing appropriate interventions

We are not going into detail concerning choice of

BTW- ICD-9 is replaced by ICD-10 on 10/1/15.

Boot Camp time

Essential elements of progress

Impact upon burden of care

Continued frequency and duration

Boot camp time…