Q&A: If the physician orders an exercise program, can I code that in section O under restorative?

Carol Maher, RN-BC, CPC, RAC-MT

Q: If the physician orders an exercise program, can I code that in section O under restorative? 

 

For example, the physician ordered “BUE pulley exercises for 20 reps x 1 in all planes daily 7x/week as tolerated.”

 

A: In order to code as restorative, the restorative plan should be documented in the medical record. For example, this appears to be an intervention for active range of motion. The name and reason for the restorative plan should be documented along with a care plan identifying the program, goal and interventions. Staff completing the program must be trained how to correctly administer the interventions. There also needs to be licensed nursing documentation of the resident’s progress towards their goals. The program must be under the direction of a licensed nurse. The minutes provided each day/treatment must be documented.



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