Name: / MR#:
HICN#: / DOS:
Facility: / Y/N or N/A / Comments
These items need to be supplied by billing office:
Copy of the ADR request
Itemized List of Charges (page 2 of the Online Claim Summary) if the FI/MAC/reviewer (such as NGS) requests this as a separate item from the UB04
UB04
FACILITY RECORDS
Include any of the documents listed below to support patient’s need for therapy or benefit from skilled intervention. Documentation should reflect patient’s prior functional level, decline in skills and progress made during therapy services
Nursing to Therapy Referral Form
MDS assessments and Resident Assessment Protocols
Physician and Nursing Progress Notes
Relevant Consultant Records
Nutrition, Social Service and Activities Records
Patient Care Plans
Diagnostic Procedures (Modified Barium Swallow Studies, X- ray reports, lab work, etc.)
Dysphagia Medical Workup
Medication Administration Records
Treatment Records
Weekly Weights, Intake / Output Records, Vital Sign Records, G-tube / IV Flow Sheets, Respiratory or Oxygen Flow Sheets
Wound Treatment Records, Skin Care Treatment Flow Sheets
Restorative Nursing Records
THERAPY DOCUMENTATION: PT
PT Therapy Evaluation / Plan of Care with complete PLOF
(signed and dated by MD within 30 days)
PT Recertifications
(signed and dated by MD within 30 days)
Delayed Certification Form if MD signature is not dated or outside 30 day window
PT Weekly Progress Notes
PT Discharge Summary
PT Daily Progress Notes
PT eDTRs (electronically approved by each therapist)
Or paper DTRs if not using the eDTR
PT Evaluation and Recertification Orders
(signed and dated by MD)
PT Caregiver Training Notes or Logs
PT Group Treatment Logs
PT Restorative Program
PT Home Assessment
PT Exception Form
THERAPY DOCUMENTATION: OT
OT Therapy Evaluation / Plan of Care with complete PLOF
(signed and dated by MD within 30 days)
OT Recertifications
(signed and dated by MD within 30 days)
Delayed Certification Form if MD signature is not dated or outside 30 day window
OT Weekly Progress Notes
OT Discharge Summary
OT Daily Progress Notes
OT eDTRs (electronically approved by each therapist)
Or paper DTRs if not using the eDTR
OT Evaluation and Recertification Orders
(signed and dated by MD)
OT Caregiver Training Notes or Logs
OT Group Treatment Logs
OT Restorative Program
OT Home Assessment
OT Exception Form
THERAPY DOCUMENTATION: ST
ST Therapy Evaluation / Plan of Care with complete PLOF
(signed and dated by MD within 30 days)
ST Recertifications
(signed and dated by MD within 30 days)
Delayed Certification Form if MD signature is not dated or outside 30 day window
ST Weekly Progress Notes
ST Discharge Summary
ST Daily Progress Notes
ST eDTRs (electronically approved by each therapist)
Or paper DTRs if not using the eDTR
ST Evaluation and Recertification Orders
(signed and dated by MD)
ST Caregiver Training Notes or Logs
ST Group Treatment Logs
ST Restorative Program
ST Exception Form
My signature confirms:
1) This record is complete and organized by category (i.e. physician orders, nursing notes, etc.) in chronological order.
2) This record includes all pertinent documents, including therapy records, from start of care through the review period in question.
3) An exact copy of the ADR packet is being maintained at the facility in case of a denial
PD/Facility Representative: Date:
Page 1 of 2 Revised March 2010