Page 68 - Rehab 2020

*Note: If discontinuing services early, you must delete any future appointments from the
calendar to avoid being assigned those furtue appointments.

Coordination Note Entries - Follow Up Care

Document coordination notes in the Notes section for the following instances during follow up care:

1. Interdisciplinary team updates
2. Family contact and conversations pertaining to the care of the patient
3. Missed visits (visits that were missed and could not be rescheduled during the work week (Sunday to
Saturday)
4. Order updates

RECERTIFICATION

When the patient approaches the end of the 60-day certification period, a decision has to be made
whether or not to recertify the patient for another 60-day certification period. In order for that to occur
there is a criteria that needs to be met as well as a procedure to be followed. Only the Case Manager (RN
or PT) can perform a recertification.

Criteria for Recertification

In order for a patient to be recertified the patient has to meet the following criteria:
1. Homebound status (Medicare)
2. Functional progress is still occurring and is documented
3. Still requires the skilled intervention of the therapist
4. Functional goals remain
5. Approval from manager

Recertification Procedure

1. Therapist contacts the manager 10 days prior to the end of the certification period in order to
obtain approval to recertify the patient
a. The manager will inquire to see if the case meets the criteria and ask for therapist’s
specific discharge plans
b. If the manager does not approve the recertification, the therapist will discontinue the
patient from their service
c. If the manager approves the recertification, continue with the next steps
60