As is most service areas, “the job’s not done until the paperwork’s done.” In the case of therapy service provided in skilled-care facilities, this means the provider therapist must provide sufficient documentation to the Centers for Medicare and Medicaid Services to meet requirements for payment.
Documentation plays a critical role in explaining the need for Medicare therapy services and justification on the use of the exceptions process. Therapy providers are required to provide documented reports of each patient’s initial evaluation, diagnosis, prognosis, and plan of care; added documentation covers followup visits, reexamination, and subsequent discharge.
Documentation should also include objective measures of the patient's improvement as a means to justify therapy services above the cap. Because documentation is usually reviewed by Medicare contract nurses, rather than therapists, it should not be assumed that the reviewer will understand why the service requires the skill of a therapist. Providers must be careful to ensure that documentation is legible, relevant, and sufficient to justify the services billed.
The Centers for Medicare and Medicaid Services (CMS) states that therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services. Documentation must comply with all legal/regulatory requirements applicable to Medicare claims. CMS outlines its minimal documentation requirement in the Medicare Benefit Policy Manual Publication, 100-02, Chapter 15, Section 220.3. Also available is a guide to educate providers on common documentation errors for outpatient rehabilitation therapy services.
In general, Medicare requires that therapy services are of appropriate type, frequency, intensity, and duration for the individual needs of the patient. Documentation should:
- Establish the variables that influence the patient's condition, especially those factors that influence the clinician's decision to provide more services than are typical for the individual's condition.
- Establish through objective measurements that the patient is making progress toward goals. CMS is aware that regression and plateaus can happen during treatment, and recommends that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.
The following types of documentation of therapy services are expected to be submitted in response to any contractor request for documentation, unless otherwise specified. The timelines are minimum requirements for Medicare payment.
Evaluation: The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings. Evaluation shall include a diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated; a Plan of Care consistent with the related evaluation; Progress Reports at least every 10 days to provide justification for the medical necessity of treatment; and discharge documentation that includes all treatment provided since the last progress report and indicates that the therapist reviewed the notes and agrees to the discharge.
All documentation must include adequate identification of the patient/client and the physical therapist or physical therapist assistant. The patient's/client's full name and identification number, if applicable, must be included on all official documents .All entries must be dated and authenticated with the provider's full name and appropriate designation.
Documentation must be authenticated, depending on the level of the therapist (skilled, assistant, student, etc.), by properly certified persons and should include indication of no-shows and cancellations.
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