- Billed services are documented (X-ray, PT, rehab)
- Special studies performed include explanation of why the test is necessary and a description of the impact the test(s) had on treatment &/or diagnostic decisions
- Diagnosis made is supported by the findings of the case
- List risk factors of a prolonged recovery (
See Appendix C)
- Conditions – diabetes, cardiovascular disease, CNS disorders, medication interactions, etc.
- Yellow flags (depression, anxiety, poor coping strategies, fear avoidant behavior, job dissatisfaction, etc.)
Treatment Plan - included? Followed?
Periodic recheck and updated treatment plan. Followed?
Exacerbations affect recovery? Home vs. work?
Were work restrictions/modifications issued? Followed?
Outcomes oriented documentation
Goal oriented management
Use of the Appeal process
Reasons for care denial
- Insurance letter/opinion
- Based on consultant file review (MD vs. DC vs. "anonymous"; qualifications included?)
- Based on IME
- Guidelines cited
- Records reviewed listed?
MMI reached? If so, when? If not, any predictions or special tests needed before MMI is reached?
Pertinent past history findings (list & describe impact to the current case)
Rehabilitation (progression from passive to active care)
- Anything more than "exercises given" listed? How frequently? Any follow-up? Any objective physical testing pre-/post-rehab to document outcomes?
- If multiple units (each 15 minutes) - is this clearly documented (what was performed, SOAP approach for rehab service, "scorecard" of performance, etc.)
Was each page signed & dated?
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