With therapy documentation being put under the microscope more than ever, you would be wise to make sure standardized assessment tools are at your fingertips. Unbiased views of data and outcomes information are what you need for care planning and execution.

With the beginning of the G-coding from Medicare Part B, the industry began to demonstrate a significant increase in the utilization of standard assessment tools. While it is not a requirement of the G-coding process with our Medicare Part B patients, it has been highly recommended to implement various assessments. This has allowed us to have the freedom to choose better assessments; however, what about when we don’t always agree with the outcome results?

The self-assessment surveys are the biggest issue with misleading data. Many times patients are not as educated at the beginning of their rehab programs as they are when they are ready for discharge from this process.

Therefore, the type of responses they provide are many times based on the limited knowledge they have of what to expect from rehab. However, after the wonderful therapy programs and results they achieve from our services, they understand the process and expectations much better.

Unfortunately, their score may appear as if their status has significantly decreased, when in reality their physical status has significantly increased. In these situations, I advise therapists that are very concerned with the G-coding system, that ultimately it is their clinical decision-making that needs to be the final decision-maker for the coding.

This is also very important to follow-up with the therapist’s documentation to support their clinical decision-making skills.

With many of the standardized assessment tools, there have been many websites and mobile apps that will help to convert the scoring systems to meet the G-coding system. This is very helpful, but it is the therapist’s clinical decision-making skills that determined these crossover tools and how to align the G-coding C-modifiers.

Although G-coding has become the most obvious aspect to incorporate standardized assessment tools, I think that the industry needs to continue to grow this aspect of our documentation and routine standardized practices.

Other benefits of utilizing standardized testing include the objective measurements that the scoring component of the assessment provides.

Our documentation is highly scrutinized these days with accusations of lack of medical necessity or improper coding errors. By utilizing any variety of standardized assessment tools, it significantly helps to show better objective data and outcomes to help justify our therapy interventions and plans of care.

Shelly Mesure (“measure”), MS, OTR/L, is the senior vice president of Orchestrall Rehab Solutions and owner of A Mesured Solution Inc., a rehabilitation management consultancy with clients nationwide. A former corporate and program director for major long-term care providers, she is a veteran speaker and writer on therapy and reimbursement issues.