Question

A new therapist working at a skilled nursing facility is documenting a recent treatment session with a client. The clinician wants to be sure that their write-up is meeting all of the standards required under medicare law to ensure the facility is appropriately reimbursed for the skilled OT services the clinician has just performed. During the documentation process the OT demonstrates the reasonable and necessary nature of the intervention and describes how the skilled service performed promoted functional use of the client's hands, while using some jargon common to occupational therapists. Feeling confident in the content of the note the therapist signs their name and hits submit without including credentials (OTR/L). Medicare will most likely do what in response to the OT's treatment note?

a. Reject the claim due to the use of jargon
b. Accept the claim, but cite the clinician with a warning
c. Accept the claim because the reviewer will be able to confirm the credentials of the clinician by comparing the note to previously submitted notes
d. Reject the claim due to the lack of credentials

Answer 1

Medicare may reject a claim if the clinician's credentials are not included in the treatment note, even if the note adequately describes the skilled OT services provided and uses appropriate professional jargon.

Step-by-step explanation:

A new therapist documenting treatment at a skilled nursing facility must adhere to Medicare documentation requirements to ensure reimbursement for occupational therapy services. The documentation process should demonstrate the reasonable, necessary, and functional nature of the intervention, a standard for skilled OT services. One key requirement is including the clinician's credentials in the treatment note. Despite the use of occupational therapy jargon and a clear description of the services provided, Medicare may reject the claim if the therapist’s note lacks the necessary credentials, such as OTR/L (Occupational Therapist, Registered/Licensed).