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Medicare Documentation Requirements

9 Sep 2019 3:33 PM | Zachary Edgar (Administrator)


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 for the Individual Needs of the Patient
  • Needs of the Patient
  • Dictated Documentation
  • Dates for Documentation

Evaluations and Re-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
  • Re-Evaluations

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

Discharge Summary

Functional Reporting (No Longer Required as of Janaury 1, 2019)

  • Services Affected
  • Providers and Practitioners Affected
  • Function-Related G-codes
  • Selecting the G-codes to use in Functional Reporting
  • Choosing the Correct Severity/Complexity Modifiers
  • Required Reporting of Functional G-codes and Severity Modifiers

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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