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Wednesday evening began with the familiar routine of back-to-school night, following my son’s class schedule as I moved from one classroom to the next.
The evening felt almost mechanical, smiling at other parents, engaging in small talk, and listening to teachers outline their objectives for the year. I quickly found myself drifting into boredom, my hand automatically reaching for a pen to take notes from the PowerPoints each teacher presented. Writing helps me stay engaged; otherwise, sitting passively would drive me batty.
Then I arrived at the English class, and everything changed. As I walked in, I spotted something that immediately caught my eye: a real-life, physical vocabulary book. It was like a portal to my past. I glanced at the teacher’s credentials on the screen: 37 years of experience. This was going to be good.
As a child, I loved vocabulary. The notebook filled with new words to learn, the thrill of filling in the blanks, the satisfaction of understanding grammar rules, it was all pure joy to me. The teacher began to explain her approach, sharing some startling facts about the decline in vocabulary and grammar usage today.
I was taken aback.
She stressed that if our children can become confident, well-spoken, and grammatically correct communicators, they will succeed in whatever field they choose. I wholeheartedly agreed.
I couldn’t help but draw a parallel to our work as therapists. Just as vocabulary and grammar are foundational for students, precise language and documentation are crucial for us in demonstrating the skilled level of service we provide.
Medicare, the primary payer for many skilled nursing facility residents, provides clear guidelines on what constitutes skilled therapy services. We have all heard the rules a million times. According to Medicare Benefit Policy Manual (MBPM) Chapter 15, therapy must be specific and effective, with a level of complexity such that it can only be safely and effectively performed by a licensed therapist.
This requirement places a significant emphasis on how therapists articulate the necessity of their services.
The language we use in our documentation must reflect the intricate and specialized nature of the care we provide. This is not just about ticking boxes but about telling a story that accurately conveys the patient’s condition, the therapeutic interventions needed and the expected outcomes.
Content and form matter
Just as a student might carefully choose the right word to complete a sentence in a vocabulary workbook, therapists must select precise language to describe the clinical reasoning behind their interventions.
Let’s break down each of the areas defined in MBPM.
Complexity and sophistication: The services should involve a high degree of professional judgment and expertise. Phrases such as “manual therapy techniques to enhance joint mobility” or “neuromuscular re-education to improve functional movement patterns” highlight the specialized skills required. Remember to use action words to show why your services are complex and sophisticated.
Patient-specific language: Documenting the patient’s specific condition and how it necessitates skilled therapy is crucial. Statements like “due to the patient’s hemiplegia, advanced proprioceptive neuromuscular facilitation techniques were utilized to enhance upper extremity motor control” demonstrate that the services provided are tailored to the patient’s unique needs. If you find this challenging, consider the above as a sentence structure and condition, followed by evidenced based technique, followed by reason.
Justification of need: There must be clear documentation of why the therapist’s skills are required. Descriptions such as “therapist’s skilled intervention required to modify and adapt exercises due to fluctuating cognitive status” provide evidence that non-skilled personnel could not have safely or effectively delivered the same care.
Outcomes and progress: Language that reflects measurable progress or the development of a maintenance program is essential. For example, “patient demonstrated a 20% improvement in gait speed following therapeutic exercises aimed at increasing lower extremity strength” not only shows progress but also ties it directly to the skilled intervention provided.
Thoughtful choices help everyone
Therapists must use their documentation to clearly demonstrate the necessity and impact of their interventions. This isn’t just about avoiding claim denials; it’s about validating the critical role that skilled therapy services play in patient care.
As we continue to refine our documentation practices, let’s draw inspiration from those vocabulary workbooks of our youth. Just as students learn to choose the right words to convey their meaning, we must choose the right language to demonstrate the value of our skilled services. By doing so, we not only meet regulatory requirements but also advocate for the profession and, most importantly, for the patients we serve.
The power of language in therapy documentation cannot be overstated. By thoughtfully applying Medicare’s guidelines and incorporating precise, patient-specific language, therapists can ensure that their documentation reflects the true complexity and necessity of their interventions.
Just as vocabulary and grammar are foundational in education, so too are they in the skilled practice of therapy.
Renee Kinder, MS, CCC-SLP, RAC-CT, serves as the Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she contributes her expertise as a member of the American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, the University of Kentucky College of Medicine community faculty, and an advisor to the American Medical Association’s (AMA) Current Procedural Terminology CPT® Editorial Panel, and a member of the AMA Digital Medicine Payment Advisory Group. For further inquiries, she can be contacted here.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
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