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Documentation Essentials

Documentation Essentials
Mylinda Barisas-Matula, MBA, OT
February 15, 2012


Welcome to all of you who are joining us today.  I certainly appreciate your time.

We are going to be talking about therapy documentation guidelines, primarily in a skilled nursing facility (SNF) setting.   These guidelines do apply to, and are best practices in any setting.   We will cover documentation guidelines as they relate to Medicare A residents as well as outpatients or Medicare B residents.  This would apply to outpatient settings or outpatients being seen in a SNF setting. 

Course Objectives

·         Provide basic Medicare coverage guidelines for skilled therapy.

·         Provide documentation and billing practices that meet the CMS guidelines.

·         Identify key terminology to document justification for skilled services.  (Very important as it relates to documentation).

·         Provide practical verbiage that can be used, today or in the future, in the field when documenting what skilled services are being provided. 

·         Review the importance of proper medical error corrections, approved abbreviations, point-of-service documentation, and legible signatures.


Medicare Coverage Guidelines

These guidelines are provided directly from the CMS Provider Manual.  Therapy services must be considered under accepted standards of medical practice and effective for the patient's condition.  What this means is they are not going to pay for experimental services.  Services must be at a level of complexity and sophistication, or the condition of the patient must be of a nature that requires the judgment, knowledge, and skills of a therapist.  The verbiage they use is important to note because we can use some of that same verbiage back when we are justifying the services that we provided.  Therapy services must be related to an active written treatment plan designed by a physician.  So a physician needs to be involved in that process.


There must be the expectation that the patient's condition will improve in a reasonable amount of time, or the services are necessary to set up a safe and effective maintenance program.  Medicare does cover setting up maintenance programs.  Lastly, the frequency and duration of the therapy services must be reasonable for the treatment of the patient's condition.  It's important, as you think about all of your documentation, for you to have all of these guidelines in the back of your head, because these are the coverage guidelines that we need to follow in order for Medicare to pay for our services.


mylinda barisas matula

Mylinda Barisas-Matula, MBA, OT

Mylinda Barisas-Matula, OT, CLT. MBA has worked with the geriatric population for over 20 years in a number of health care venues including outpatient clinics and SNFs in both operational and clinical roles. Mylinda most recently worked as a Rehabilitation Consultant and provided education and resources nationally on CMS regulation specific to rehabilitation services.  Mylinda has provided MDS 3.0 and documentation educational in-services at both the facility level and at professional conferences.  Currently, Mylinda also serves on the Occupational Therapy Affiliated Credentialing Board for the State of Wisconsin. 

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