Are you making evaluation complexity coding too complex? Don’t make this more difficult than it is! Instead of trying to navigate all of the fancy terminology being used to educate us on how to correctly code complexity, let’s try looking at it plain and simple.
Here are some common problems that have already been discovered and tips for improvement (in plain language):
1. Clinical Decision Making
Clinical reasoning and decision making occurs throughout the evaluation as the clinician decides which questions to ask, what assessment tools and tests to use, identifying goals, deciding what modifications are necessary, etc. Keeping in mind all decisions being made through the course of the evaluation and documenting/justifying those decisions will provide support of the complexity chosen.
2. Patient History
Consider what you need to know about the patient’s medical history to make clinical decisions and develop a skilled POC. Be sure to clearly document all aspects of the patient’s history that you used to determine the plan and goals. Explain specifically how the patient’s medical history is impacting the current POC and your approaches to therapy intervention.
3. Occupational Profile
OT should document detailed description of the occupational profile. Use an Occupational Profile worksheet to assist. If you don’t already have a worksheet, create one for your OTs to help guide the narrative within the documentation. AOTA has provided an occupational profile template. Utilize the available tools from your associations and simply describe the areas within the evaluation.
4. Formal Tests
In order to accurately code the complexity of the evaluation, formal testing must be completed. Make frequently used tests readily available. With the new coding, it is necessary to go ahead and complete at least one formal test on day 1 with the initial evaluation and summarize the results within the POC. This is another component to accurately coding the complexity of the evaluation. Be sure to update the results of the selected tests at re-cert and DC as well.
5. All Criteria Required
Remember that you must code “down” if all criteria for the complexity level is not met. All criteria must be met (and documented) for each complexity level.
Keep in mind that the evaluation is still the same evaluation! Consider that by coding the complexity level, this is really just a way to ensure that we are documenting more thoroughly and justifying our services. I think that often we take for granted the skill and sophistication that we provide. Document your thinking process as you are creating the plan for your patients. No one else is able to do what you do!
Cassie Murray, OTR, IASSYC CYB
Cassie Murray is the Executive Director of Clinical Services for Healthcare Therapy Services. A 1994 graduate from Indiana University in Occupational Therapy, Cassie has over 22 years of experience in long term care, hospital, outpatient and home health. She provides support for HTS therapists and partnering communities through program development, training on regulatory requirements and ongoing quality assurance. She is active in state and national associations such as Leading Age, AHCA, NASL, AOTA. Her passion for rehabilitative services is inspired from personal experience with her father suffering a stroke while Cassie was in high school. This lead to her successful career path in occupational therapy.