Knowledge Base Article

Please share this article with the therapists at your facility.

In last week’s Wednesday@One, we discussed therapy documentation in the evaluation, re-evaluation, plan of care, and certification. This week we will note some potential areas of improvement for therapy documentation in the daily treatment notes, progress notes, and the discharge summary. Like last week, we encourage providers to review the

Daily Treatment Notes

• Daily notes should list each specific intervention/modality provided to the patient for both timed and untimed codes.
• Medicare requires that the treatment notes include the total treatment time in minutes (includes both timed and non-timed codes) and the total minutes of the timed codes. Therapists need to know which treatments are timed codes and which are non-timed codes.   Non-timed codes are reported as one unit per day while the total number of units allowed for timed codes is restricted by the total timed code treatment minutes. For example if a patient receives 10 minutes of therapeutic exercise, 10 minutes of neuromuscular re-education and 10 minutes of manual therapy, the total timed code minutes equals 30 minutes which is 2 units. This patient may have also received 20 minutes of unattended electrical stimulation; this is included in the total treatment time for a total of 50 minutes, but does not affect the calculation of timed code units since it is an untimed code.
• Units of timed codes are based on the following time scale:
• 8-22 minutes = 1 unit
• 23-37 minutes = 2 units
• 38-52 minutes = 3 units
• 53-67 minutes = 4 units, etc.
• The therapy professional(s) providing the treatment must sign the treatment note and include their credentials.
• Extra documentation in the daily notes, though not required, often helps to support medical necessity in case of a Medicare audit. This may include noting the patient’s response or any assistance / instruction the patient required. If pain is part of the patient’s functional deficit, a numeric evaluation or discussion of the patient’s pain is recommended.
• Some LCDs list specific requirements for certain therapy services. For example, Cahaba’s Physical Therapy LCD notes that the medication and dosage information is required for iontophoresis and, for manual therapy, the area(s) being treated and the soft tissue/mobilization technique used should be documented. Be sure to review your Medicare contractor’s coverage policies for any additional documentation requirements.

Interval Progress Notes

• After the evaluation, this is the most important documentation in supporting the medical necessity of the therapy services provided. Based on our reviews of therapy records, most progress reports consistently contain all of the required elements.
• These notes must include objective measurements that describe the patient’s current function. Note that under the new functional limitation reporting requirements, the patient’s function will be reported as a percentage of impairment which must be documented in the patient’s record.
• Progress notes that allow easy comparison of the patient’s initial status and the status at last progress interval to the current status make auditing the record easier. The original and any revised goals need to be listed or referenced by a numbering system and the patient’s progress toward each goal noted.
• The clinician must document an assessment of the patient’s progress or lack of progress. Clearly explain if the patient is on target, ahead of schedule or not progressing as expected including reasons, adjustments to treatments / goals and recommendation for continuation of treatment. Remember this is where the therapist makes his/her case for the medical necessity of continuing treatment.

Discharge Summary

• A discharge note or summary is required for each episode of outpatient treatment.
• It covers the period from the last progress note to the date of discharge.
• In the case of an unanticipated discharge, the therapist uses the daily treatment notes and verbal reports from the treating assistants to make judgments for the summary.
• The discharge note requires the same elements as an interval progress note and is the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed.

When documenting therapy services, remember that you are presenting a “story” to justify that

1. the patient has a condition for which therapy should be beneficial,
2. the services require the skills of a therapist, and
3. the services are appropriate for the individual needs of this particular patient.