Knowledge Base Article

When Medicare reviewers audit your records, your documentation should “tell a good story.” For example, for rehabilitative therapy does your record tell what was wrong, when it happened, how it affected the patient’s life, why skilled services are needed, which services are needed and for how long and often, that a physician was involved in the patient’s care, and finally what was the patient’s outcome? I also review therapy records and complete, accurate documentation tells a compelling story of a patient’s therapy episode.

The first CERT Task Force scenario is a guide to educate providers on common documentation errors for outpatient rehabilitation therapy services. In addition to actual pre- and post-payment reviews, Medicare Administrative Contractors (MACs) provide feedback and education to providers through publication of their review findings, direct provider education, and now through collaboration with each other and the CERT review program. Certain A/B MACs are working together through the CERT A/B MAC Outreach and Education Task Force to educate providers on costly claim denials and billing errors to Medicare with an ultimate goal of reducing the national payment error rate.  

This focus on therapy services is timely as April is National Occupational Therapy month. In addition to sharing some of the key points from this guide, MMP would like to acknowledge the valuable contribution of Occupational Therapists to healthcare. The older I get, the more I value the ability to perform the physical functions necessary to lead an active lifestyle and to accomplish simple activities of daily living. When age, illness, or injury impairs function, occupational therapists are there to help patients restore and maintain their abilities.

In addition to their technical skills, all rehabilitative therapists must document their services in a manner consistent with Medicare’s documentation requirements. According to the CERT Task Force guide, “The leading cause of payment errors for therapy services is ‘insufficient’ documentation in the medical records.” Therapy documentation is often missing the required elements as outlined in applicable local coverage determinations and the Medicare manuals.

Here are some of the key documentation elements from the guide, LCDs, and the Medicare manuals.

• Plan of Care must include:
• The patient’s diagnoses (helpful to include functional limitations)
• Measurable long term goals for the entire episode of care
• Type of therapy (PT, OT, or SLP) (helpful to describe specific treatments, such as therapeutic activities, neuromuscular reeducation, etc.)
• The amount, duration and frequency of services
• Legible, dated signature and professional identity of the person establishing the plan and the practitioner certifying the plan
• Treatment notes must include:
• Date of treatment
• Specific intervention(s) provided and billed
• Total timed code treatment minutes and total treatment time in minutes
• Signature and professional identification of the qualified professional who furnished the services
• Functional Reporting
• Nonpayable G-codes and severity modifiers reported on claim must be documented in the therapy record
• Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.

I encourage therapists to review the CERT Task Force guide, as well as the Medicare manuals and LCDs for therapy services for a complete discussion of the documentation requirements. I realize a lot of documentation is required, but good therapy documentation paints a complete and accurate picture of the patient’s conditions, the need for therapy, the treatments provided, and the patient’s ultimate outcome. For my nerdy, healthcare brain, it is like reading a good novel!