I was recently notified of a recognition that I would be receiving from my alma mater, the University of Kentucky.

The congrats email was soon followed by a slew of others on setting a date, the process for inviting guests, scheduling pictures and so forth, all of which began with an interview from a very kind gentleman who wanted to discuss how the university impacted my progress and, in his words, career success.

Little did he know this kind of thing is beyond torturous for me.

A Virgo and an Enneagram 3 … all I can come up with as his gingerly begins his questioning over Zoom are all the epic fails along the way.

“What do you mean I am ‘Hall of Fame’? … So I missed the Young Alumni phase?” Bummer. 

My mind keeps spinning, never made a “30-under-30” or “40-under-40” list. Was unsuccessful in attempts to join MedPAC, MedCAC… oh, the interviews and tests I have bombed. The times I almost passed on during presentations due to nerves. And the list goes on, and on, and on.

Still so much left to do, and lots and lots of failed launches on this road to “progress.” 

Come on, Renee, don’t torture this interviewer, I think.

“Specifically,” he asks, “what do you recall from your time here at the university that lead to your growth?”

“Knowing the rules and asking questions,” I respond.

The final takeaway that I recall from university training, thank you Dr. Deem, was to ask for the rule or proof of what is being recommended in clinical practice. 

What I have learned since then is that if we want to advocate for change in the future, we must understand and respect the history of the rules that govern our practice now. 

I can recall, like it was yesterday, 11 years ago and my first day on the job in a clinical role. My boss at the time asked me to come prepared to review Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services.

Not the company policies, or the human resource manuals, but the “gold standard,” as she put it, when it comes to understanding the rules of practice and documentation for Medicare.

Prepared I came that day. Literally to the level that I made flashcards for all the areas and attempted to memorize as much of the content as possible for purposes of impressing her with my ability to swiftly regurgitate regulatory jargon. 

“The conditions of coverage and payment for outpatient physical therapy, occupational therapy or speech-language pathology services are as follows.” And, are you aware that, “The plan of care shall contain, at minimum, the following information as required by regulation: diagnoses; long-term treatment goals; and type, amount, duration and frequency of therapy services.”

I was on top of the world with my newfound knowledge and understanding of why and how we are asked to code, document and support our services.

And did you know “skill” has criteria? All this time I was confused with the term skill being associated with Medicare Part A. As therapists, we are accountable with showing skill for all those we serve. My mind was blown!

Still to this day I review this manual every January. And still to this day, I learn something new every time. I recommend you do the same.

Staying on the theme of progress, for today’s purposes and as we move into a new year full of opportunities for personal, and professional improvement, let us consider what is required of us, per MBPM Chapter 15 when documenting patient progress.

Content of Clinician (Therapist, Physician/NPP) Progress Reports. The progress report of a clinician shall also include:

  • Assessment of improvement, extent of progress (or lack thereof) toward each goal
  • Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report
  • Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment
  • Objective reports of the patient’s subjective statements, if they are relevant. For example, “Patient reports pain after 20 repetitions”. Or, “The patient was not feeling well on 11/05/06 and refused to complete the treatment session.”
  • Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occur
  • Descriptions shall make identifiable reference to the goals in the current plan of care. Since only long-term goals are required in the plan of care, the progress report may be used to add, change or delete short-term goals

Furthermore, care must be taken to assure that documentation justifies the necessity of the services provided during the reporting period, particularly when reports are written at the minimum frequency.

Justification for treatment must include, for example, objective evidence or a clinically supportable statement of expectation that:

  • In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
  • In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status, and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.

2023 is upon us now.

Know the rules, aim for personal and professional progress daily, and don’t forget to help others on their own paths to success along the way.

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she serves as a member of American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Current Procedural Terminology CPT® Editorial Panel. She can be reached at [email protected].

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.