Palmetto GBA expects the following elements of documentation to be submitted in response to any requests for documentation unless we specifically request otherwise. Document as often as the clinician’s judgment dictates, but no less than the frequency required in Medicare policy:
- Evaluation/Plan of Care (may be a single document or two separate documents). Include the initial evaluation and any re-evaluations relevant to the episode being reviewed.
- Certification (physician/non-physician practitioner (NPP) approval of the plan) and recertification when records are requested after the certification/recertification is due. Certification (and recertification of the plan when applicable) are required for payment and must be submitted when records are requested after the certification or recertification is due.
- Progress Reports (including Discharge Notes, if applicable) when records are requested after the reports are due.
- Treatment Notes for each treatment day (may also serve as Progress Reports when required information is included in the notes)
- A separate justification statement may be included either as a separate document or within the other documents to document the practitioner’s reasoning for providing services that are more extensive than is typical for the condition treated. A separate statement is not required if the record justifies treatment without further explanation.
Limits on Requirements: Palmetto GBA requires more specific documentation unless other Medicare manual policies require it. Palmetto GBA may request further information to be included in these documents concerning specific cases under review when that information is relevant, but not submitted with records.
Dictated Documentation: For Medicare purposes, dictated therapy documentation is considered completed on the day it was dictated. The qualified professional may edit and electronically sign the documentation at a later date.
Dates for Documentation: The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan. However, contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the Progress Report or Treatment Note refers. For example, if treatment began on the first of the month at a frequency of twice a week, a Progress Report would be required at the end of the month. Palmetto GBA may require that the Progress Report that describes that month of treatment be dated not more than one week after the end of the month described in the report.
Document Information to Meet Requirements: In documenting records, clinicians must be familiar with the requirements for covered and payable outpatient therapy services as described in the manuals. For example, the records should justify:
- The patient is under the care of a physician/NPP:
- The physician/NPP care shall be documented by physician/NPP certification (approval) of the plan of care
- Although not required, other evidence of physician/NPP involvement in the patient’s care may include, for example: order/referral, conference, team meeting notes and correspondence
- Services require the skills of a therapist:
- Services must not only be provided by the qualified professional or qualified personnel, but they must require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently. A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each Progress Report Period. In addition, a therapist’s skills may be documented, for example, by the clinician’s descriptions of their skilled treatment, the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.
- A therapist’s skill may also be required for safety reasons, if an unstable fracture requires the skill of a therapist to do an activity that might otherwise be done independently by the patient at home. Or the skill of a therapist might be required for a patient learning compensatory swallowing techniques to perform cervical auscultation and identify changes in voice and breathing that might signal aspiration. After the patient is judged safe for independent use of these compensatory techniques, the skill of a therapist is not required to feed the patient, or check what was consumed.
- Services are of appropriate type, frequency, intensity and duration for the individual needs of the patient:
- Documentation should establish the variables that influence the patient’s condition, especially those factors that influence the clinician’s decision to provide more services than are typical for the individual’s condition. Clinicians and contractors shall determine typical services using published professional literature and professional guidelines. The fact that services are typically billed is not necessarily evidence that the services are typically appropriate. Services that exceed those typically billed should be carefully documented to justify their necessity, but are payable if the individual patient benefits from medically necessary services. Also, some services or episodes of treatment should be less than those typically billed, when the individual patient reaches goals sooner than is typical.
- Documentation should establish through objective measurements that the patient is making progress toward goals. Note that regression and plateaus can happen during treatment. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.
Needs of the Patient: When a service is reasonable and necessary, the patient also needs the services. Contractors determine the patient’s needs through knowledge of the individual patient’s condition and any complexities that impact that condition, as described in documentation (usually in the evaluation, reevaluation, and Progress Report). Factors that contribute to need vary, but in general they relate to such factors as the patient’s diagnoses, complicating factors, age, severity, time since onset/acuity, self-efficacy/motivation, cognitive ability, prognosis, and/or medical, psychological and social stability. Patients who need therapy generally respond to therapy, so changes in objective and sometimes to subjective measures of improvement also help establish the need for services. The use of scientific evidence, obtained from professional literature, and sequential measurements of the patient’s condition during treatment is encouraged to support the potential for continued improvement that may justify the patient’s need for therapy.
Resource: