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Rehabilitative Therapy Documentation, Part 1

Published on 

Wednesday, May 29, 2013

Please share this article with the therapists at your facility.

With all of the new Medicare requirements for rehabilitative therapy, such as functional limitation reporting, cap amounts applied to hospital outpatient services, and manual medical review of therapy services exceeding the threshold, we thought now would be a good time to address therapy documentation. These Medicare requirements can be found in the Medicare Benefits Policy Manual, chapter 15, section 220.3. Also most Medicare Administrative Contractor shave local coverage determinations for therapy services that include additionald ocumentation requirements.

The Medicare Benefits Policy manual details the minimum documentation requirements for therapy services. They also list documentation elements that are “encouraged” though technically not “required.” But this is a catch 22 –therapy documentation must be sufficient to support the medical necessity of the services provided. The manual states, “It is encouraged but not required that narratives that specifically justify the medical necessity of services beincluded in order to support approval when those services are reviewed.” So, like Medicare, we encourage providers to cover their bases with the amount and type of therapy documentation.

We are not going to re-list all of the documentation elements that Medicare recommends to support therapy services. Most therapists are well aware of the documentation requirements but we recommend providers carefully review the Medicare Benefits Policy Manual and any therapy LCDs for their jurisdiction for complete documentation information. We are going to discuss a few elements we have identified during therapy audits that we believe have potential for improvement. This week we will address documentation in the therapy evaluation, re-evaluation, plan of care and certification.

Evaluation

  • Onset date – this is usually documented on the evaluation/certification form though the exact onset date is often hard to pin down. Our recommendation involves chronic conditionsa nd those conditions with an insidious onset. To support medical necessity, we recommend the evaluation answer these questions - If this condition has been going on for a while, why is therapy needed now? Has there been a recent decline in function, increase in pain or stiffness, increase in number of falls, or an exacerbation of the condition,etc.? Is the therapy intended to improve function or prevent further decline? Documentation that clearly addresses these questions helps to support the medical necessity of the therapy services.
  • ADLs, ADLs, ADLs – The evaluation will include the patient’s functional deficit with objective measurements, but discussing the patient’s prior function and current limitations in terms of activities of daily living helps to support the medical necessity of the planned therapy. It is great to know the patient has limited mobility or restricted range of motion, but understanding the patient is unable to go grocery shopping or dress themselves is more dramatic and convincing of the need for treatment.

Plan of Care

  • ADLs Again – In addition to the objective measures in the goals, linking the goals to improvement in a particular activity of daily living makes the goal more meaningful to the patient and to an outside reviewer.
  • The functional impairments identified and expressed in the long term treatment goals must be consistent with those used in the claims-based functional reporting, using non-payable G-codes and severity modifiers.

Re-evaluation

  • Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation.
  • Re-evaluations are indicated when there are new clinical findings, a significant change in thepatient's condition, or failure to respond to the therapeutic interventionsoutlined in the plan of care.

Certification

  • Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. Make sure the signature of the certifying practitioner is dated and be sure to include a copy of the signed certification when submitting records for external review. Medicare may deny services if a signed certification if not available in the medical records submitted for review.
  • Let’s discuss timing of the certification -Certifications should be obtained as soon as possible after the plan of care is established or at least within 30 days of the initial treatment. Certifications are acceptable without justification for 30 days after they are due but certifications delayed beyond this time frame should include evidence to justify the delay.Evidence that the provider made immediate and on-going attempts to obtain the certification signature should be included in the record. Note however that delayed certifications are accepted by Medicare unless the contractor has reason to believe that there was no physician involved in the patient’s care, or treatment did not meet the patient’s need (and therefore, the certification was signed inappropriately).

Next week, we will look at daily treatment notes, progress notes, and the discharge summary.

 

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.