No, I’m not talking about the speech therapy licensure requirements. I’m referring to:

1. Medical Complexities

2. Medical Co-Morbidities

3. Medical Conditions

How do you justify the reason for rehab, length of stay and intensity of treatment? You thoroughly explain how the 3 C’s impact the plan of care and justify the course of treatment.

Often, I’m asked how we justify the rehab RUGs with our treatment plans and documentation. My response is always, what do the patient’s 3 C’s look like? If you have two patients with the same primary diagnosis, and patient No. 2 has five more medical complexities and co-morbidities, it can be assumed that this individual will take longer to recover, may require more treatment and possibly require a longer stay to achieve the same recovery outcomes as patient No. 1.

The challenge for the clinician: have you documented these facts?

When defending claims and fighting denials, many times, I write additional addendums and letters of justification to better explain how the patient’s 3 C’s resulted in the treatment plan provided and why it was medically necessary. The key is building stronger documentation practices from the beginning.

The other factor is that this basic aspect of documentation and treatment planning should have no relevance to the insurance type. However, if the patient is Medicare Part A or Part B, we’ll need to follow the regulations for documentation requirements and supervisory visits.

Lastly, the 3 C’s should also be reflected in our discharge summaries. We can reiterate how the patient was able to achieve his or her final outcomes despite or because of documented medical complexities, co-morbidities and primary conditions.

There will never be a perfect guide to documentation, but understanding the clinical reasoning and theory behind all our documentation practices will help strengthen our claims.