NBCOT Documentation and Service Management 4 — Questions and Answers
Question 1: Under HIPAA, which of the following is considered a legitimate reason for an OT to disclose a client's protected health information (PHI) without written authorization?
- Sharing records with the client's employer upon request
- Disclosing information to a family member who pays the bill
- Reporting a communicable disease to public health authorities as required by law (Correct answer)
- Providing records to a research team studying OT outcomes
Correct answer: Reporting a communicable disease to public health authorities as required by law
HIPAA permits disclosure of PHI without authorization for mandated public health reporting activities such as communicable disease notification.
Question 2: A therapist documents 'Client appears unmotivated and uncooperative.' This type of entry is problematic primarily because it:
- Uses subjective, judgmental language rather than objective behavioral observations (Correct answer)
- Is too brief to satisfy Medicare documentation requirements
- Fails to include a functional goal tied to the client's diagnosis
- Does not identify the specific intervention technique used
Correct answer: Uses subjective, judgmental language rather than objective behavioral observations
Clinical notes must reflect objective, observable behavior rather than subjective characterizations that can reflect bias and are not measurable.
Question 3: Which document outlines the specific services to be provided, frequency, duration, and measurable goals agreed upon at the start of OT services?
- Discharge summary
- Daily treatment note
- Plan of care (POC) (Correct answer)
- Referral order
Correct answer: Plan of care (POC)
The plan of care formally establishes the scope, frequency, duration, and goals of OT services and requires physician signature in most reimbursement settings.
Question 4: An OT working in a skilled nursing facility (SNF) must demonstrate 'skilled care' in documentation to justify Medicare Part A reimbursement. Which entry BEST demonstrates skilled care?
- Client performed grooming independently with setup assistance
- Client requires maximum assist for bathing due to left hemiplegia
- Therapist graded resistance and cueing during dynamic balance training to safely progress client toward functional ambulation on uneven surfaces (Correct answer)
- Client attended therapy session and completed all exercises as instructed
Correct answer: Therapist graded resistance and cueing during dynamic balance training to safely progress client toward functional ambulation on uneven surfaces
Skilled care documentation must reflect the therapist's clinical judgment, complexity of service, and why the intervention requires a licensed professional.
Question 5: When a client's progress has plateaued but maintenance therapy is recommended, the OT's documentation should focus on:
- Demonstrating ongoing restoration of function with new measurable gains
- Justifying the need for a skilled therapist to prevent decline and maintain current functional level (Correct answer)
- Documenting that the client has met all discharge criteria
- Requesting a referral to a different discipline
Correct answer: Justifying the need for a skilled therapist to prevent decline and maintain current functional level
Medicare and most payers cover maintenance therapy when a skilled professional is required to safely carry out or design the maintenance program, even without new functional gains.
Question 6: A client signs a release of information form requesting that records be sent to their attorney. Which action is MOST appropriate?
- Send only a summary note rather than the full medical record
- Fulfill the request per facility policy, sending only the records specified in the authorization (Correct answer)
- Contact the attorney directly to determine what they need before releasing anything
- Refuse because attorney requests do not qualify under HIPAA
Correct answer: Fulfill the request per facility policy, sending only the records specified in the authorization
A valid signed authorization allows release of the specific records identified; the therapist should follow facility policy and honor the scope of the signed authorization.
Question 7: Which functional outcome measure is MOST commonly used to document occupational performance in activities of daily living for inpatient rehabilitation settings and directly aligns with reimbursement documentation?
- Canadian Occupational Performance Measure (COPM)
- Functional Independence Measure (FIM) (Correct answer)
- Assessment of Motor and Process Skills (AMPS)
- Kohlman Evaluation of Living Skills (KELS)
Correct answer: Functional Independence Measure (FIM)
The FIM is the standard ADL outcome measure embedded in the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI) used for Medicare reimbursement.
NBCOT Documentation and Service Management 4
Under HIPAA, which of the following is considered a legitimate reason for an OT to disclose a client's protected health information (PHI) without written authorization?