Documentation to Support Skilled Rehab Services Workshop 

Learning Objectives

1. Identify primary documentation strategies to support medical necessity of therapy claims in the SNF/LTC setting.

2. Identify appropriate variables to consider and document when developing the intensity plan and selecting RUG levels.

3. Understand and remedy common reasons for medical review denials based on insufficent documentation and lack of functional progress outcome reporting.

4. Understand key clinical considerations for discharge transitions and documentation principles to justify skilled services for full duration of care.

5. Identify critical components of effective and efficent interdisciplinary Medicare meetings.

6. Demontrate competence in therapy specific ICD-10 coding fundamentals for the October 1 transition from ICD-9 to ICD-10.

Amie Martin, OTR/L, CHC, RAC-CT, Principal Consultant & Director of Operations for Proactive Medical Review & Consulting, LLC

Amie is an occupational therapist with over twenty years of experience serving in long term care rehabilitation leadership positions and as a clinical program specialist. She is certified in healthcare compliance through the Health Care Compliance Association. She has successfully partnered with post-acute care and rehabilitation service providers to improve clinical outcomes, compliance programs, medical record documentation, and to reduce error rates under medical review. Working with legal counsel to prepare defensive arguments and provide expert witness testimony, she has defended rehabilitation providers under large volume ZPIC and RAC government audits, recovering reimbursement on denied claims. Amie’s recent publications include articles for the American Occupational Therapy Association, American Association of Nurse Assessment Coordination (AANAC), American College of Health Care Administrators, and the American Health Lawyers Association. She has presented extensively to SNF health care associations and national groups such as NARA (National Association of Rehabilitation Providers and Agencies) and AANAC on documentation and Medical Review related topics.

Stacy Baker, OTR/L, RAC-CT, Clinical Consultant

Stacy is a graduate of University of Southern Indiana with over ten years of long term care experience as an occupational therapist and multi-site manager. She has served as a mentor and clinical instructor, specializing in geriatric clinical program development, post-acute quality care and reimbursement, and medical review management. She currently serves as a clinical consultant for Proactive Medical Review & Consultants, LLC providing clinical instruction, quality assurance medical record auditing, and medical review response assistance in approximately 100 mid-west based skilled nursing facilities.

Proactive Medical Review & Consulting  assists post-acute care providers in ensuring compliance with regulatory standards and promoting measurable care excellence. Proactive specializes in SNF risk assessment, Quality Assurance Performance Improvement (QAPI) projects, medical record review services and staff development to promote care quality and effective clinical documentation. Proactive offers consulting for Medial Review and Medicare Appeals, and is uniquely positioned to assist SNF providers with therapy oversight and the defense of skilled rehab services through their team that includes Therapist consultants in addition to Nurse, Health Facility Administrator, MDS and SNF/NF billing experts.