Documenting therapy and rehabilitation services

The CERT A/B MAC Outreach & Education Task Force, a partnership of all A/B Medicare Administrative Contractors, created this guide to educate providers on common documentation errors for outpatient rehabilitation therapy services.

These widespread errors contribute to Medicare’s national payment error rate, as measured by the Comprehensive Error Rate Testing (CERT) program.

The leading cause of payment errors for therapy services is “insufficient” documentation in the medical records. Documentation is often missing the required elements as outlined in applicable local coverage determinations and the CMS Internet Only Manual Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230 external pdf file.

For example, a provider indicates in the medical record: “Plan of Care: We would like to see the patient three times per week to initiate exercises and modalities to decrease pain and increase range of motion, stretching, strengthening and function.”

"This plan is missing key elements to support the medical necessity of the service, such as measurable long term goals, the patient’s diagnosis, the proposed type, duration and frequency of services required to achieve each goal, or anticipated plan of discharge."

Additional widespread issues that result in “insufficient” documentation errors include:

• Missing or illegible signature on the plan of care;
• Missing or illegible signature for physician’s certification;
• Missing legible signature and required treatment minutes in narrative or on flow sheet.

The CERT A/B MAC Outreach & Education Task Force recommends providers carefully review the following documentation requirements and tips for ensuring complete and accurate medical records.

Contents of plan of care

The plan of care shall contain, at minimum, the following information as required by regulation:

• Diagnoses
• Long term treatment goals -- Should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care.
• Type -- May be physical therapy, occupational therapy, or speech language pathology, or when appropriate, the type may be a description of a specific treatment of intervention. When a physician or non-physician practitioner (NPP) establishes a plan, the plan must specify the type of therapy planned.
• Amount -- Refers to the number of times in a day the type of treatment will be provided. When amount is not specified, one treatment session a day is assumed.
• Duration -- Number of weeks or the number of treatment sessions for the plan of care.
• Frequency of therapy services -- Refers to the number of times in a week the type of treatment is provided. When frequency is not specified, one treatment is assumed. The plan of care shall be consistent with the related evaluation. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources.

Signature and certification of the plan of care

The legible signature and professional identity (e.g., MD, OTR/L) of the individual who established the plan, as well as the date it was established, must be recorded with the plan. A physician or NPP must certify (and date) the plan of care (*note: for CORF services, NPPs may not order or certify therapy services).  Certification may be established in the patient’s medical record through:

• Physician’s or NPP’s progress note
• Physician or NPP’s order*
• Plan of care that is signed and dated by a physician/NPP*

Documentation must indicate that the physician/NPP* is aware that the therapy service is or was in progress; and agrees with the plan, when there is evidence the plan was sent to the physician/NPP, or is available in the patient’s medical record for the physician/NPP to review.

Treatment note

The purpose of treatment notes is to create a record of all treatments and skilled interventions that are provided and to record the time of the services to justify the use of billing codes and units on the claim. Documentation is required for every treatment day and every therapy service. Documentation of each treatment note must include the following required elements:

• Date of treatment.
• Identification of each specific intervention/modality provided and billed (both timed and untimed codes).
• Total timed code treatment minutes and total treatment time in minutes.
• Signature and professional identification of the qualified professional who furnished the services; or, for incident to services, supervised the services, including a list of each person who contributed to the treatment.

Functional reporting Claims for therapy services that are required to contain the nonpayable G-codes and corresponding modifiers should include documentation of Functional Reporting in the medical record.

Specifically, documentation of the nonpayable G-codes and severity modifiers regarding functional limitations reported on claims must be included in the patient’s medical record of therapy services for each required reporting interval as outlined in the MBPM.

Documentation of functional reporting must be completed by the clinician furnishing the therapy services. Therapists must also document his/her clinical judgment in the assignment of the appropriate severity modifier.

Avoid CERT errors: Tips to improve therapy documentation

• Ensure the medical records submitted provide proof the service(s) was certified and rendered.
• Ensure the medical records provide justification supporting medical necessity and that skilled services were needed.
• Create a complete plan of care, making certain to include your legible signature, professional identification (e.g., PT, OTR/L) and date the plan was established.
• Document when the plan of care is modified, including how it has been modified and why the previous goals were not met or could not be met.
• Confirm the plan of care is certified (recertified when appropriate) with physician/NPP legible signature and date.
• Clearly document, in minutes, the total time spent on timed-code treatment only and the total treatment time (including timed and untimed codes) in the patient’s record.

 

The Efficient Therapist

“Hello,” Charlie said as he entered the treatment room.  "I'll be your physical therapist."

Calista sat on the edge of a cushioned table.  She looked up.  Her right leg lay on the table wrapped thigh-to-ankle in white cotton with velcro straps.  She wore Florida Gator flip-flops, white soccer shorts and she sat on the table with her other foot on the floor. 

She had torn her anterior cruciate ligament during a college tournament game three days ago.  Surgery over the weekend had repaired the ligament. 

The surgery hadn’t hurt much but Calista was still upset from her injury.  The immobilizer prevented her knee from bending.  She had cried this morning while trying to put on her pants.  She couldn’t walk very well either on her two crutches.  While getting in her Mom’s car, she had almost fallen down.  While her Mom looked on anxiously, Calista tried to laugh at herself but just started crying again.

Charlie introduced himself and exchanged brief pleasantries with Calista.  She was better composed now and bantered easily with Charlie.  He felt relaxed.  He had thirty minutes to examine Calista and write up her plan of care.  “That should be plenty of time”, Charlie thought.

He began his examination by visually inspecting Calista’s knee, ankle and hip.  He took her range of motion.  He tested her strength.  He felt her lower leg for a pulse and checked her deep veins with careful probing.  While Charlie performed these tasks he asked Calista,  “I see that you have your most difficulty with putting on shoes and socks and getting in and out of he car.  Is that correct?”

She gave him a curious glance, “Yes, I can’t bend my knee”.

Charlie saw her look, “I’m just going by the answers you put on this questionnaire.”  He showed her his iPod opened to the tab with the Knee injury and Osteoarthritis Outcome Scale (KOOS).  The radio buttons were all checked and the total score was already tallied at the bottom.

“I didn’t know how to answer some of those questions.  It asked about Running which, obviously, I can’t do,”  she tried to smile.

“You did fine”, Charlie said.  “Your scores will improve as your knee gets better.  This test helps me show your progress.”  He paused, and then added, “It’s like a mutiple choice test for your knee,” he grinned and looked up at her.

She gave him another strange look.  She thought he was teasing her.

Charlie saw his mistake.  “Sorry, I’m kind of new to these questionnaires, too.  We just started using them last year.  I learned about them in school but I never used one until I started working at this clinic,” he looked at her to see if she was paying attention to him.  She looked interested.

Emboldened, Charlie continued, “Believe it or not, the scores from these questionnaires accurately measure your progress.  They’ve been tested on other young athletes with injuries like yours.”

“How will this help me?” asked Calista.

“Well, they help me determine when we can safely progress your treatment.”  Charlie was silent a moment as if in thought.  He added, “They’re also pretty helpful in writing up your initial evaluation.  They save me a lot of time.”

“How so?”, she asked, encouragingly.

“Well, the computer writes your first two or three treatment goals based on your highest scores from the test.  That saves a couple of minutes right there,”  he showed her his iPod.  Charlie opened a new tab labeled Goals.  On it was written the following:

1. Improve KOOS Sports/Recreation score from 65 to 73 in 10 visits.
2. Improve KOOS Quality of Life score from 60 to 68 in 10 visits.

“I don’t know what that means,” said Calista.  “How do my scores compare to other people like me.”

Charlie opened another tab, read for a moment and said, ”The average post-surgical KOOS score for Sports is about 60 and Quality of Life is about 55.  It looks like you’re above average!” he grinned again.

Calista wasn’t going to let Charlie off that easily, ”But why does the computer set my goal so low?  I want to get 100% better!”

“The computer sets your goal at something called the Minimum Clinically Important Difference.  For the KOOS, research suggests 8 points is the minimum,”  Charlie tried to sooth his patient.  “When we reach your goal, the computer asks me if we should continue.  If I say yes, you will fill out another KOOS and a new goal will be calculated.  It’s a little like reaching the ten-yard line in football,” he ventured.  This time she liked his analogy.  She smiled and he beamed.

Calista wanted to move the conversation back to her knee but she asked Charlie one more question because he seemed so eager.  “Why ten visits?  My surgeon said three months.”

“Well, that’s the rules,” he said.  “Its actually driven by Medicare policy which says Progress Notes every ten visits.  Some clinics just want to make it easier to manage so they make every goal 10 visits.  I can set that for more or less, if I want.”

“Hmmm,” said Calista.  She was becoming bored with his technology.  She definitely wanted Charlie to focus his attention back to her. She was glad he was competent and well-informed but she really just wanted her therapist to attend to her needs.