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General Documentation Requirements

Documention Requirements

These types of documentation of therapy services are expected to be submitted in response to any requests for documentation. The timelines are minimum requirements for Medicare payment. Document as often as the clinician’s judgment dictates but no less than the frequency required in Medicare policy:

  • Evaluation and Plan of Care (may be one or two documents). Include the initial evaluation and any re-evaluations relevant to the episode being reviewed;
  • Certification (physician/NPP approval of the plan) and recertifications when records are requested after the certification/recertification is due. Certification (and recertification of the plan when applicable) are required for payment and must be submitted when records are requested after the certification or recertification is due;
  • Progress Reports (including Discharge Notes, if applicable) when records are requested after the reports are due;
  • Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes).

In preparing records, clinicians must be familiar with the requirements for covered and payable outpatient therapy services. For example, the records should justify:

The Patient is under the Care of a Physician/NPP

 Physician/NPP care shall be documented by physician/NPP certification (approval) of the plan of care; and Although not required, other evidence of physician/NPP involvement in the patient’s care may include, for example: order/referral, conference, team meeting notes, and correspondence.

Services Require the Skills of a Therapist

Services must not only be provided by the qualified professional or qualified personnel, but they must require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently. A clinician may not merely supervise but must apply the skills of a therapist by actively participating in the treatment of the patient during each progress report period. In addition, a therapist’s skills may be documented, for example, by the clinician’s descriptions of their skilled treatment, the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.

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.

Clinicians and contractors shall determine typical services using published professional literature and professional guidelines. The fact that services are typically billed is not necessarily evidence that the services are typically appropriate. Services that exceed those typically billed should be carefully documented to justify their necessity, but are payable if the individual patient benefits from medically necessary services. Also, some services or episodes of treatment should be less than those typically billed, when the individual patient reaches goals sooner than is typical.

Documentation should establish through objective measurements that the patient is making progress toward goals. Note that regression and plateaus can happen during treatment. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.

Needs of the Patient

When a service is reasonable and necessary, the patient also needs the services. Contractors determine the patient’s needs through knowledge of the individual patient’s condition, and any complexities that impact that condition, as described in documentation (usually in the evaluation, re-evaluation, and progress report). Factors that contribute to need vary, but in general they relate to such factors as the patient’s diagnoses, complicating factors, age, severity, time since onset/acuity, self efficacy/motivation, cognitive ability, prognosis, and/or medical, psychological and social stability. Changes in objective and sometimes to subjective measures of improvement also help establish the need for rehabilitative services. The use of scientific evidence, obtained from professional literature, and sequential measurements of the patient’s condition during treatment is encouraged to support the potential for continued improvement that may justify the patients need for rehabilitative therapy or the patient’s need for maintenance therapy.

Dictated Documentation

For Medicare purposes, dictated therapy documentation is considered completed on the day it was dictated. The qualified professional may edit and electronically sign the documentation at a later date.

Dates for Documentation

The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan. However, contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the progress report or treatment note refers. For example, if treatment began on the first of the month at a frequency of twice a week, a progress report would be required at the end of the month. Contractors may require that the progress report that describes that month of treatment be dated not more than 1 week after the end of the month described in the report.

Reference

Centers for Medicare and Medicaid. Medicare Benefit Policy Manual Ch. 15 ยง 220

Local Coverage Determination (LCD): Outpatient Physical and Occupational Therapy Services (L34049)

Local Coverage Determination (LCD): Therapy and Rehabilitation Services (L33413)


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