Knowledge Base Article

On January 31, 2019, Palmetto GBA, the Medicare Administrative Contractor (MAC) for Jurisdictions J and M, published the following instruction regarding coding for therapy records.

Can we use the therapy progress notes and/or the plan of care documentation without the Physician or Nurse Practitioner signature to code from for Medicare claims? 

Yes, you may use the therapist intervention notes to help support your codes. You are allowed to do that for Medicare purposes. Make sure that the physician is informed on the therapist activities and you will still need to forward those notes to the physician at some point.

This is not the gift it may originally seem and I want to offer some cautions associated with this instruction. First, what would be the benefit of doing this? The MACs may have edits in place for therapy claims that require specific diagnoses in order to be paid. When physicians/practitioners order therapy services, they may list the medical diagnosis on the order, for example, “status post meniscectomy for left lateral meniscus tear.” But the therapist is not technically treating the meniscus tear or the meniscectomy, but the associated functional deficits caused by the repair. (I had one of these, so I know!) They are treating the joint pain, swelling, limited range of motion, gait issues, etc. associated with the surgery. The therapist describes these functional diagnoses in the evaluation and plan of care, with objective measures and subjective observations supporting these limitations. This makes it easy to see why coding from the therapist’s documentation makes sense to more accurately describe the “diagnosis” for the therapy services. And if edits are indeed in place for the payor, these diagnoses are more likely to “pass” the edits for a functional diagnosis and allow your claim to be paid.

But most state laws do not allow therapists to diagnose patients, so your coders will have some heartburn with this instruction. And do NOT let this instruction make your therapists think this makes it acceptable to delay obtaining the physician/practitioner’s signature on the plan of care. Medicare requires the patient to be under the care of a physician/practitioner and their certification of the plan of care. This certification shows the physician/NPP approves of the therapist’s plan and gives permission for the therapist to move forward with the approved plan. Therapists do not have to wait on the signature to begin treatment, but a signature certifying the plan is required for Medicare payment and Medicare expects this to be done in a timely manner, i.e. as soon as possible after the plan is established. This means that if the record is audited by a Medicare reviewer, there must be a plan of care certification signed by the patient’s physician/practitioner in the medical record. If this documentation is missing, Medicare will deny the claim.

How likely is it your therapy claim will be reviewed by Medicare? That is hard to know, but currently 7 of the 12 MAC Jurisdictions have therapy services as a topic of their Targeted Probe and Educate (TPE) reviews, and 8 of the 12 MACs have a Local Coverage Determination and/or Coverage Article addressing therapy services. I would say the odds are not looking good for escaping scrutiny.