Palmetto GBA has noticed an increase in documentation issues related to therapy services. You may receive requests for medical records from Medicare for a variety of reasons. Requests may also come from several different Medicare contractors. Record requests may be related to any of the following:
Review of a Medicare contractor, through the Comprehensive Error Rate Testing (CERT) program
- More information is required before the Medicare contractor can process the claim
- Review of a new physician or practitioner to ensure a good understanding of Medicare claim submission and documentation guidelines
- Review of an established physician or practitioner before or after the claim is paid based on analysis of data
- Investigation of a complaint alleging possible fraud or abuse of the Medicare program
Through recent medical review analysis, providers failed to submit documentation of the required 'therapy plan of care' and/or 'certification' for the dates of service billed. Please remember, outpatient therapy services furnished to a beneficiary by a provider or supplier are payable only when furnished in accordance with certain conditions. The following conditions of coverage apply:
- Services are or were required because the individual needed therapy services
- A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP
- Services are or were furnished while the individual is or was under the care of a physician
- Services must be furnished on an outpatient basis
- All of the conditions are met when a physician/NPP certifies an outpatient plan of care for therapy. Certification is required for coverage and payment of a therapy claim.
The following types of documentation for therapy services are expected to be submitted in response to any requests for medical records unless Palmetto GBA requests otherwise.
- Evaluation/Plan of Care (may be one or two documents). Include the initial evaluation and any re-evaluations relevant to the episode being reviewed
- Certification (physician/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) is 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. (At least once every 10 treatment days or at least once during each certification interval, whichever is less.)
- Treatment notes for each treatment day (may also serve as progress reports when required included information is in the notes)
- A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands the reasoning for 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.
It is vital that you include all of the requested records. Before responding to the request, always double-check to ensure that you have included all relevant information.
In sections 220.1, 220.1.2 and 220.1.3, find additional therapy coverage (PDF, 1.21 MB) regarding plan of care and recertification references.