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ABC’s of Medicare Documentation

Medicare overhauled the therapy documentation requirements in 2006 at the time that regulations for the therapy caps exception process were published.  Some regulations were updated, some were clarified, and new regulations were added.  Additionally there is an increasingly likelihood that rehab providers will be selected for claims review, either from a medical records process (review the chart) or a claims-based process (electronic review of edits, codes, and the therapy caps).

Course Description:

This basic course reviews the current Medicare documentation requirements, including a step-by-step breakdown of these requirements.  The basics of ICD-9 coding are reviewed, and a more detailed review of the CPT-4 procedures codes is undertaken.  Following this course, participants will be able to improve individual documentation in support of skilled care and medical necessity requirements, including meeting the requirements of the local coverage determination.


  1. Understand Medicare requirements for meeting skilled care and medical necessity
  2. Understand key Medicare documentation elements and how to present these elements in a logical fashion to support medical necessity
  3. Demonstrate knowledge of diagnosis and procedure coding
  4. Learn how to effectively document with ‘language’ that supports goals, function, and links to coding
  5. Understand the critical aspects of PLOF and CLOF in meeting medical necessity requirements
  6. Demonstrate the efficient use of recording minutes, flow sheets, attendance logs, superbills, outcomes measurement, and the other ‘paper’ that is filling up the chart
  7. Understand application of the CCI edits


Nancy J. Beckley, MS, MBA, CHC

Course Format:

This is a basic, but essential course can be designed for a half day or full day seminar.  The format is lecture, with practical demonstration and problem solving on coding.  .

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