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Medicare Therapy Documentation Changes

13 Nov 2021 11:04 AM | Zachary Edgar (Administrator)

Sample Audit Form - Can be used to audit outpatient therapy documentation. 

General Documentation Requirements

  • Document Requirements
  • The Patient is under the Care of a Physician/NPP
  • Services Require the Skills of a Therapist
  • Services are of Appropriate Type, Frequency, Intensity and Duration 
  • Needs of the Patient
  • Dictated Documentation
  • Dates for Documentation

Evaluations

  • When it is Appropriate for an Initial Evaluation
  • Contents of an Evaluation
  • When the Evaluation is the Only Service Provided
  • When the Evaluation Serves as the Plan of Care
  • Additional Assessments
  • Evaluations by Multiple Disciplines

Plan of Care

  • Establishing the Plan of Care
  • Elements of the Plan of Care
  • Modifying the Plan of Care

Certification and Re-certification of the Treatment Plan

  • What does it mean to have the plan of care certified?
  • Do I need an order/prescription/referral from a physician/NPP?
  • When does the POC need to be certified?
  • Is the initial treatment date when I began treating the patient or when I performed the evaluation?
  • How long do certifications last?
  • What happens if I can’t get the plan certified within ninety (90) days?
  • Do I need to submit additional evidence to justify the delay?
  • Who must certify the POC?
  • Which practitioners are not allowed to certify a plan of care?
  • Can I have the physician/NPP sign a document other than the POC?
  • Are verbal certifications acceptable?
  • When does the POC need to be recertified?
  • What happens if the recertification is delayed?
  • What happens if my claim is denied due to certification issues?


Progress Reports 

  • Timing of the Progress Report
  • Content of the Progress Report
  • Clinician’s Participation in the Report
  • Assistant’s Participation in the Report

Treatment Notes

  • Required Elements
  • Optional Elements
  • Additional Tips for Notes
  • Making Changes to the Note
  • Signature on the Note
  • Identification of the Supervisor

Reevaluations

  • Who may Perform a Reevaluation?
  • Role of the Assistant
  • When can a Reevaluation be Performed?
  • Reimbursement
  • Content of the Reevaluation
  • Billing for a Reevaluation
  • Documentation

Discharge Summary

  • What is Required in the Discharge Note?
  • Unanticipated Discharge
  • Optional Information

    Medicare Signature Requirements

    • Which outpatient therapy documentation requires and signature and who must sign?
    • What is required for a valid signature?
    • What if I use a scribe when documenting medical record entries?
    • How are orders treated differently than other medical documentation?
    • What should I do if I did not sign an order or medical record?
    • What if I signed the order or progress note but my signature is not legible?
    • What is a signature log?
    • What if I do not have a signature log in place?
    • Am I able to attest to my signature?
    • Do my signatures need to be dated?


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