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Rendering providers must document all evaluations, re-evaluations, services provided, member progress, attendance records, and discharge plans. All documentation must be kept in the member's records along with a copy of the referral or prescribing provider's order. Documentation must support both the medical necessity of services and the need for the level of skill provided. Rendering providers must copy the member's primary care provider (PCP), prescribing provider and/or medical home on all relevant records.
All documentation must include the following:
Health First Colorado requires the following types of documentation as a record of services provided within an episode of care: initial evaluation, re-evaluation, visit/encounter notes and a discharge summary.
Written documentation of the initial evaluation must include the following:
Plan of Care
A detailed Plan of Care must be included in the documentation of an initial evaluation. This care plan must include the following:
An episode of outpatient therapy is defined as the period of time from the first day the member is under the care of the clinician for the current condition(s) being treated by one therapy discipline until the last date of service for that plan of care for that discipline in that setting.
The therapist's plan of care must be reviewed, revised if necessary, and signed, as medically necessary by the member's physician, or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law at least once every 90 days.
The care plan may not cover more than a 90-day period, or the time frame documented in the approved IFSP.
A plan of care must be certified. Certification is the physician's, physician's assistant or nurse practitioner's approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. If the service is a Medicare-covered service and is provided to a member who is eligible for Medicare, the plan of care must be reviewed at the intervals required by Medicare.
A re-evaluation must occur whenever there is an unanticipated change in the member's status, a failure to respond to interventions as expected or there is a need for a new plan of care based on new problems and goals requiring significant modification of treatment plan. The documentation for a re-evaluation need not be as comprehensive as the initial evaluation, but must include at least the following:
Written documentation of each encounter must be in the member's record of service. These visit notes document the implementation of the plan of care established by the therapist at the initial evaluation. Each visit note must include the following:
In addition to the above required information items, the visit note documentation must contain the Subjective, Objective, Assessment and Plan format elements. These may be documented in any order (i.e. SOAP, APSO, etc.)
At the conclusion of therapy services, a discharge summary must be included in the documentation of the final visit in an episode of care. This must include the following:
Colorado Department of Health Care Policy & Financing
Physical and Occupational Therapy Billing Manual