In October 2005, Palmetto GBA, the home care intermediary for 16 eastern and southern states, published a new policy to provide guidance on Medicare payments for home health agencies to provide teaching and training for families and other caregivers of Medicare beneficiaries with Alzheimer's disease and behavioral symptoms.


The policy recognized that families and other caregivers of Medicare beneficiaries with Alzheimer's disease and behavioral symptoms may need help in learning to manage behavioral symptoms. The Medicare rationale for this training is that controlling of behavioral symptoms will help maintain the patient's physical, mental, and medical health.


Therapists have a significant role in providing this service because behavioral symptoms may be impacting the patient's mobility and safety, as well as the patient's communication and performance of basic care tasks. Reducing behavioral symptoms may be the key to improving these areas. This means that the majority of your treatment may be focused on caregiver training, and your goals will be met when the caregiver has demonstrated competence in the teaching techniques.


Treatment and Documentation Considerations When Patient has a Cognitive Deficit

  1. Making the shift from
    • Teaching the patient to teaching the caregiver
    • Impairment-based practice to abilities-based practice
    • Rigid protocols to individualized, adapted plans
  2. Identify and document the person's abilities; e.g.,
    • Can follow a simple, one-step command with demonstration
    • Able to focus on an activity for a short period of time
    • Able to sustain an action or movement for a short period of time
  3. Identify what motivates the person (use this in treatment)
  4. Identify who can benefit from teaching, the patient, the patient and the caregiver, or only the caregiver
  5. Create a safe and effective maintenance program
  6. Promote independence by teaching the caregiver how to cue the patient
  7. Provide caregiver training in task analysis/simplification, environmental adaptations
  8. Provide treatment that matches the cognitive abilities of the patient
  9. Document the education
  10. Document the competency of the caregiver
  11. Discharge when the caregiver is competent

Within the homecare environment, audits are on the horizon due to the relationship between therapy visits and reimbursement. An auditor may deny a single visit if it is determined that the therapy visit was not reasonable or necessary. That loss of one visit could have a significant impact on the agency's reimbursement for that case.


The therapist must be able to document the service so it is reimbursable. Let's look at the basics in documentation.

  1. The therapy service must be reasonable. If the majority of your treatment is caregiver education, does your frequency and duration make sense?
  2. The therapy service must be necessary. Are the skills of a therapist needed? Remember the skilled therapy service must be provided with the expectation of:
    • the condition of the patient will improve materially in a reasonable and generally predictable period of time; or
    • the services are necessary to the establishment of a safe and effective maintenance program (this is the program that you would be teaching the caregiver)

Components of Good Documentation


Paint a professional picture of the patient

  • Utilize standardized tests and measures (e.g., the Allen battery)
  • Use words that demonstrate skill (observation, evaluation, management, instruction)
  • Support the medical necessity of the service
  • Document the HEP and/or Maintenance Program

Goal Writing

  1. Goals must be functional—if the goal is for improved strength, there must be a goal that indicates the need for strengthening (e.g., to be able to walk from bed to bathroom; to be able to complete LB dressing) (this defines why the goal is important to the patient).
  2. Goals need to be realistic—(do not write goals for independence if that is not realistic; progress could be improving a pt. from moderate cognitive assistance to minimal assistance). Independent means "safe, efficient and effective" (a person may do things alone, but this does not mean the person is independent).
  3. Goals need to be measurable—( a goal for someone to be at a minimal assistance is measurable; a goal for maximum rehab. potential is not).
  4. Goals need to identify the person who is receiving therapy and who will carry out the HEP or Maintenance Program.

Treatment Documentation

  1. Describe your treatment as it relates to your expected outcomes: (Pt. engaged in LB strengthening exercises with increased repetitions and endurance facilitating mobility throughout the home with intermittent verbal cues from caregiver for safety). Describe any environmental changes or adaptations you facilitated in the home. List recommendations and whether or not the pt. and/or caregiver plans to carry out those recommendations.
  2. Provide an evaluation/ assessment of progress in each note. (Pt. demonstrating improved ability to _______ with appropriate cueing from caregiver). —"tolerated well" is not an assessment.
  3. If progress is slow or there are setbacks, document this information; e.g., describe fluctuations in abilities due to fatigue or pain. This is one way to justify the duration of your treatment.
  4. Indicate when a goal is met—do not wait until the end of the frequency to say all goals are met and/or the caregiver is demonstrating competency. If goals are only partially met, the lack of progress should have been documented and the goals should have been changed to more realistic ones.

The skills of a therapist require the art of good documentation. We should not let the fear of an audit dictate the care we provide. Our patients with dementia and the caregivers have the right to receive Medicare reimbursed services. Remember these tips to avoid the audits.