Medicare no longer views the physician signed approval of the plan of care as necessary and sufficient to prevent over-utilization. Now, as always, the physical therapist is responsible for providing the appropriate amount of physical therapy services.
The difference now is there will not be a signed note every month from the doctor that ‘tells’ the physical therapist to do physical therapy. There will only be the clinical decision-making of the physical therapist.
When reviewing the physical therapists notes in the chart to determine if the services provided were appropriate, Medicare auditors will look at three things, primarily.
1. Were the services Medically Necessary?
2. Were the services delivered skilled? That is, could a lesser-trained person (such as an aide) have delivered the services at less cost to the Medicare program?
3. Did the patient improve the expected amount in a reasonable time frame?
The physical therapist can write the re-certification note so as to demonstrate these three criteria.
Prior to 2008, many facilities did not distinguish between the Re-certification Note and the Progress Note.
Prior to 2008, the Progress Note was due every ten treatment sessions or once per month, whichever was less.
Prior to 2008, the Re-certification Note was due every ten treatment sessions or every calendar month, whichever was greater.
In 2008, the requirements for the Progress Note have not changed but the Re-certification is now only required every 90 days.
Start the Note
Just as you would in the evaluation, start the Progress Note with a Re-evaluation.
First, measure the Functional Limitations with the OPTIMAL (Outpatient Physical Therapy Instrumented Movement Assessment Log). See this video for the exact way to use the OPTIMAL score sheet.
Specifically, check the patient-identified limitations that they would most like to see improved. Compare them with their initial scores.
Have you set long-term goals using functional limitations? If so, has the patient met their goals?
Next, measure the impairments in range-of-motion that you linked to functional limitations in your initial physical therapy diagnosis. Compare the new measurement with the initial measurements. Did you set goals for these impairments? Did the patient meet their goals?
Finally, check off the goals that have been met and set new goals. If you recommend the patient continue physical therapy then you should set new goals. Remember, you want to demonstrate significant improvement in an expected time frame. The new goal should still reflect the expected time frame you identified in your evaluation.
For instance, the initial goal was to improve OPTIMAL overhead lifting (frozen shoulder) from a 4/5 to a 2/5. You spent 4 weeks doing stretching and PROM and the patient can now passively range her arm overhead. You might set the new goal to increase external rotator muscle strength from X to Y (see this video for the exact technique to measure external rotator muscle strength).
Now the physical therapist must sign the note. The PTA cannot write the Progress Note. The PT must see the patient at least once during the 10 session treatment period and the Progress Note session is sufficient.