Palmetto has published an updated list of active medical reviews. Pertaining to outpatient therapy, 2 of the active medical reviews include CPT code 97110 (therapeutic exercise) and 97140 (manual therapy) provided in non-private practice settings. It’s important to document not just what the patient performed in therapy that visit, but what did the therapist or assistant do for the patient that visit that required the unique skills of a therapist, or an assistant under the direction and supervision of the therapist, to provide.
Did the therapist or assistant provide verbal instruction and/or correction to the patient during the performance of the exercises? Did they provide visual instruction and/or correction to the patient during the performance of the exercises? Did they provide technique or posture correction to the patient during the performance of the exercise? Is the therapist documenting the manual techniques being provided (grade of joint mobilization, direction of mobilization, end-feel, etc.)? Are you taking range of motion measurements prior to and after manual therapy techniques every so many visits? Are you documenting functional deficits of the patient as well as how the patient is improving in the performance of functional tasks/activities due to your skilled therapy services of exercises and/or manual therapy techniques?
Do you have questions about documentation? I have 2 recorded webinars on documentation that were recorded earlier in 2019. Part 1 is Documentation for Evaluations and Reevaluations and Part 2 is Documentation: Everything After the Initial Evaluation.
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