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Skilled, Reasonable & Necessary – Defensible Documentation for Balance Impairments



Documenting and testing balance and falls risk in the home is integral in certifying reasonable and necessary skilled care for therapists and nurses. Learn how to use the appropriate tests and measures to make every visit defensible.

Resource Tool: Visit Note Checklist

References: Guide to PT Practice, 3rd Edition

Recording Available


Defensible documentation to ensure medical necessity and the skilled need of a therapist remains one of the top denial reasons when home health medical records are audited by fiscal intermediaries as well as Recovery Audit Contractors (RACs). The Centers for Medicare & Medicaid (CMS) has made it clear that documentation to ensure reimbursement for skilled services under the Medicare Home Health Part A benefit is the responsibility of the clinician, providing regulatory guidance to assist therapists in meeting coverage criteria for payment. Professional bodies, such as the American Physical Therapy Association (APTA), have clear standards related to documentation by licensed therapists in all settings where care is provided. These standards have recently been updated in the Guide to Physical Therapy Practice, 3rd Edition, incorporating the International Classification of Function (ICF) model as a platform to support utilization parameters. Unfortunately, therapists continue to have difficulty when documenting commonly provided services, such as evidence-based balance interventions.

This webinar will provide participants with the GO TO resource for home care therapists and assistants in documenting balance impairments and skilled interventions defensibly. This will ensure that clinicians will meet professional and industry standards rather than personal or industry “expert” recommendations. In addition to this, all participants will receive a Visit Note Checklist for the home health clinician to use as a documentation guide. Additionally, auditors of therapy documentation can enhance current processes by incorporating this checklist into their reviews. 

Upon completion of this webinar course, participants will be able to:

1. Define what
“skilled, reasonable and necessary” means for coverage of therapy services under the Medicare Part A Home Health benefit.

2. Identify key elements of objective documentation of balance impairments for both restorative and maintenance patients in the home health setting.

3. Identify key elements of defensible documentation of balance interventions for both restorative and maintenance patients in the home health setting.

4. Write thorough and accurate assessment component of visit notes for patients receiving balance interventions.

Target Audience: Clinical Supervisors, Nurses, Physical Therapists, Occupational Therapists, Speech-Language Pathologists