Documenting the Skilled Provision of Therapeutic Exercise

Physical Therapy Continuing Education Online
August 12, 2015
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UHC and other payers are auditing claims and often denying the 2nd or 3rd unit/s of therex – particularly when the treatment plan includes use of a bicycle, which may extend to treadmills or other similar equipment.  These payers are taking the position that this is an activity the patient can do independently, is therefore not skilled and not payable.

Therapists and assistants often do not adequately document the skilled provision of therapeutic exercises.  In the past, payers rarely scrutinized therapy documentation and providers got into the habit of simply completing a treatment grid noting the particulars of the therapeutic exercise program without documenting skilled care.  

To help you avoid denials due to lack of skilled care, the following are a few examples of how to document the need for this type of intervention:

  • Problem: decreased joint ROM post-operatively. Goal: increased ROM using a functional activity.  Documentation would include notation of seat height, pain, cadence, etc. and accompanying increased ROM and decreased pain achieved at the start of the ride, during the ride and the end of the ride.  Modifications in the bicycle program over time would be evident.
  • Problem: cardiopulmonary compromise decreasing endurance. Goal: increased exercise tolerance to a particular functional level (based on prior activity level) without risk of cardiopulmonary event.  Documentation would include assessment of vital signs (BP, pulse, respiration and pulse oximetry) before, during and following use of the bicycle, monitoring to ensure vital signs stay in safe parameters and including time for vital signs to return to normal.  Improvement in cardiopulmonary function and exercise tolerance should be evident from the record.  Part of skilled coverage is skilled therapy to avoid a negative outcome.
  • Problem: decreased functional ability due to neuromuscular deficit, such as hemiplegia.  Goal: increase function via repetitive motion, motor unit recruitment, cross education.  The bicycle routine may include a certain amount of time with the good extremity alone, the affected extremity alone, and both extremities.  The routine may include changes in the height of the seat and the bicycle program (speed, resistance, etc.) to increase muscle response.  The documentation would indicate these variations.  A pre- and post-gait observation or performance of a function test may show improved gait, function, etc.  There may be limited carry over initially but over time improved carry over may also be evident from the record.   

This is not meant to be an exhaustive overview of all of the benefits of use of a bicycle as part of a treatment plan, but should give you some guidance as to how to avoid or at least minimize denials for lack of skilled care.