There are a lot of myths, misconceptions and fears about functional limitation reporting. The bottom line is that clinicians who see Medicare patients after July 1, 2015 must use functional limitation codes on their documentation for the initial evaluation, at least once every 10 visits, and at the time of discharge or they won’t get paid.
All practitioners need is an EMR system that prompts them to select one of the functional limitation measures and the goal codes at the appropriate time. It’s then a simple matter of sending the claim to the clearinghouse and on to Medicare for approval and payment. Functional limitation reporting is essentially a goal-oriented process.
The judgment of the physical therapist is critical in meeting functional limitation reporting requirements. Therapists will need to document the patient’s condition at the initial visit, the selected treatment plan, severity of the client’s limitation and the expected outcome when therapy is completed.
In Touch EMR™ provides clinicians with prompts for all the information, G-codes and modifiers needed and at the appropriate times to remain within compliance. The data automatically goes into the patient file for transmission.
Documentation to support every decision, measure taken and treatment is critical. Therapists must maintain a record of the patient’s level of function upon their initial visit using their best clinical judgment, combined with the information obtained from the patient.
Listen closely to what the client says and observe their range of movement to accurately select the level of severity under which they’re functioning. Meticulous records are necessary to document the condition of the patient at each treatment session and when the patient is discharged from further therapy. The process begins again if further treatment is required.
The EMR clinicians choose should have the ability to prompt them at the three major checkpoints of functional limitation reporting – initial evaluation, the 10th visit, and at discharge. In Touch EMR™ provides practitioners with that functionality, making it easy to remain in compliance and get paid.