As with any other condition, treating cognitive impairment is supported by documentation. Although Medicare issued a statement in 2001 to all Medicare contractors that the diagnoses of Alzheimer's and/or Dementias must not be reviewed solely for the diagnosis, review still can be triggered due to inappropriate "pairing" of Medical and Treatment Diagnosis.


Medical necessity, reasonable and necessary, and the need for skilled therapy must be evident when a claim is reviewed.


Each Progress Note is not only a written statement of goal progression but a written support of why skilled intervention is necessary. How do you prove medical necessity beyond a doubt to a contractor who is reading your documentation—one who doesn't know you, your patient, or the circumstances surrounding the treatment?


ICD-9 Codes, Medical and Treatment
The first step in avoiding denials is appropriately coding the intervention. On your evaluation and on the claim form, make sure that all relevant diagnoses are entered. It is advised to talk to the business office manager regarding how to communicate these important supporting ICD-9 codes.


Alzheimer's (331.0) and Dementias (290.0—290.4) as a Primary Medical Diagnosis alone can still result in a review. If any other Medical Diagnosis is in the chart that presents a condition or complexity impacting length of treatment, include that also.


If there is no other Medical Diagnosis besides Alzheimer's or Dementia, then your Treatment Diagnosis is even more important. A progressive cognitive impairment, like other progressive disease, has inherent declines. While these declines may be predictable, your task is to maintain the highest level of function to slow the process and reduce caregiver burden.


As much as possible AVOID 780.99, Decreased Functional Activity, and/or 799.3, Debility unspecified, as a Treatment Diagnosis. These "catch all" treatment codes alone do not at first sight, tell the story as to why you were needed. Delve deeper into WHY skilled intervention is needed.


For example, ask yourself, if because of the disease and possible "excess disability," have the muscles atrophied. Then 728.2, Muscle disuse atrophy, might be appropriate. If this is the case, then your treatment plan would be to find appropriate activities/interests to encourage ROM and muscle use in keeping with cognitive level. The caregiver and/or Activities would then be trained on the type of responses and activities that encourage ROM and muscle use.


If there is an Imbalance of Posture (729.9) with seating and/or ambulation, your documentation must support why this is a risk or need for skilled intervention. Also consider Difficulty in Walking, 781.2, Abnormality of gait, Muscle weakness, 728.87, as signs or conditions that can be improved with appropriate adaptations.


Observe the person at more than one meal. Caloric intake may vary throughout the day. Persons with ADRD generally eat best at breakfast, but nursing facilities often have the highest caloric meal at lunch (783.21, Weight Loss, 783.3, Feeding Difficulties).


Cognition drives the physical performance. If the cognition is impaired, we must make every attempt to elicit the highest cognitive level and enhance the physical status. By pairing the most specific risk or condition with the Cognitive Diagnosis, initial request for review can be avoided.


Documenting Interventions
Nursing documentation is not always reliable as support for therapy intervention. If your clinical observations and/or screen suspect that a person is not functioning at their best ability, you can ask the charge nurse to enter your observations in the chart. Identify the "risks" that this lack of maximum function poses.

For example:


  • Immobility presents the risk of contractures, skin breakdown, reduction in ROM, and pneumonia.
  • Wandering presents the risk of falls and elopement and can indicate anxiety, agitation, and lack of security/comfort.
  • Verbal outbursts, resistance to care, or withdrawal/isolation can present the risk for nutritional/fluid deficiencies, skin/hygiene concerns, or use of unnecessary medications.
  • Inability to recognize or communicate needs presents the risk of dehydration, unidentified/unmanaged pain, and falls.

Document what your concern is. Whether it is withdrawal or outbursts, there is an environmental trigger that needs to be modified. Determine the highest Level/Mode and describe how the caregiver needs to be trained.


A reviewer does not know you, the person, or the environment. Your notes will have to create the picture of:

  1. Why skilled intervention was needed.
  2. What functional or physical risk was reversed/reduced.
  3. Caregiver training and return demonstration.

All in a "reasonable and necessary" amount of time. As you discover how to elicit a function or reduce a behavior/risk, be sure to document:

  • Type of communication strategies needed (relate to developmental age)
  • Latency of response
  • Environmental changes required
  • Link to function and safety

Goals relate to the deficiencies you found and always need to include the function you are eliciting or maintaining.




OT       Patient will dress upper body with minimal physical assist and moderate cognitive cueing, processing cues within 10 seconds.
PT       Patient will walk 100 ft. to the dining room using a rolling walker with minimal physical assist, supervision, and intermittent verbal cues for safety.
SLP     Patient will attend to a structured task of interest for 15 min. intervals with intermittent verbal, visual, and tactile cues for redirection.


Nursing notes and MDS information may be in conflict with your findings. Remember that nursing is reporting on a 24-hour, 7-day observation period and includes their routine approaches. Your findings may need to be specific to time and type of approach since behaviors and abilities may vary during the day. In such a situation, the above goals could be more specific to accommodate these variances:




OT       Patient will dress upper body (during a.m. cares or undress upper body with p.m. cares) with minimal physical assist and moderate cognitive cueing, processing cues within 10 seconds.
PT       Patient will walk 100 ft. to the dining room (for the evening meal) using a rolling walker with minimal physical assist, supervision, and intermittent verbal cues for safety.
SLP     Patient will attend to a structured task of interest for 15 min. intervals with intermittent verbal, visual, and tactile cues for redirection (during Activities or shift change to reduce wandering or outbursts).


Regarding length of treatment, each session, depending on a person's cognitive level, may take 45 to 60 min. due to latency of response, environmental stimuli, etc. Establishing a best ability may take five treatments. Training the caregivers and reviewing carryover and return demonstrations may take another five treatments. While these are just suggestions, a reviewer will look at the total amount of interventions to determine if it was reasonable. Co-morbidities are also factors involved and should be documented as such.


How to Respond to Denial or ADR
First of all, you need to maintain contact with the Business Office. Very often, therapists are not aware of a request to review the documentation. A Medical Records person usually sends the substantiating documentation for the claim time period.

It is recommended that if your documentation is included in the request, that you review it and if necessary send a cover letter to defend the intervention. Highlight the difference in function or the program established to maintain highest level of function.


If the initial review is denied, there are five levels of appeal.


  • Redetermination (different personnel from the initial determination)
  • Reconsideration (performed by Qualified Independent Contractors, QICs)
  • Administrative Law Judge Hearing
  • Appeals Council Review
  • Judicial Review in U.S. District Court (dispute must be more than $1,090)

If you are reading this, you have been trained in the Allen Cognitive Levels. Use your resources for assistance in documentation. When you document, ask your peers if you clearly stated the condition or risk and if your treatment diagnosis could be more specific. Ask the caregivers for input on a short-term goal that would make a difference to them. Success in their eyes can be documented in the nursing notes.


It will be the "light bulb" moments that engender caregivers and Activities to see the person through your eyes. You are the person who will discover not only "prior level of function," but also "hidden & best level of function."