Question:

What are the documentation requirements for respiratory rehabilitation services?

Answer:

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to Medicare upon request. All documentation must demonstrate the clinical rationale for skilled intervention. Clinicians are required to document all activities, tasks, instruction, and treatment provided. This documentation must be done each time the patient receives any RTR service. The patient’s medical record must contain documentation that fully supports the medical necessity for RTR services as covered by Medicare. This documentation includes, but is not limited to, relevant medical history, physical examination, and the results of pertinent diagnostic tests or procedures. It may be reasonable and necessary for multiple clinicians, ordered by the physician, to address a patient’s particular needs. Each clinician must then perform an individualized skilled evaluation within the clinician’s scope of practice and specific area of expertise. Each of the individualized evaluations will identify the problems leading to the development of a specific plan of treatment and the setting of specific goals.

This question was answered in our Coding Essentials for RT/Pulmonary Function. For more hot topics relating to respiratory services, please visit our store or call us at 1.800.252.1578, ext. 2.

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