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199: The Must-Know Documentation Guidelines From A Utilization Reviewer

Feb 05, 2024

You do not want to miss this episode!! On today’s show we address one of the most popular topics of discussion among therapists - DOCUMENTATION! The aspect of the job we love to hate. It can be so confusing to know what to include, how to justify, how to demonstrate medical necessity, and on and on. Lucky for you we have a PT Sparky who works as a utilization reviewer. Rachel Walker, DPT, GCS, CBIS, CLWT, CCI is here today and can explain it all!

We asked our audience and social media what their biggest struggles were when it comes to documentation and got through as much as we could in the time. Not only do we answer your challenging questions, Rachel also put together a free guide for documenting medical necessity, documenting skilled interventions and providing smart phrase goals you can start using right now to put your mind at ease!

A few topics discussed include:

  • The must-haves for compliance with documentation
  • What the specific terms and phrases are that reviewers are looking for
  • Why being specific about the prior level of function and establishing medical necessity is critical
  • Which outcome measures are most helpful and which to avoid
  • How to write assessments that will pass a review including phrases to use and ones to avoid
  • Spontaneous recovery vs skilled therapy
  • What constitutes the need for skilled therapy and what doesn’t
  • How to document for skilled maintenance
  • What maintenance therapy means and who qualifies
  • What the key points are for documenting when the patient’s status is either maintaining or declining
  • Why not having a caregiver is not a reason for maintenance therapy 
  • What “medical complexity” really looks like (hint: it’s not just a diagnosis)

Download your free documentation guide below:

Documentation Guide PDF

Documentation Guide Word doc

Functional Outcome Measure Chart