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.

 

Physical Therapy Services Billed by Physicians in Florida Have a High Error Rate

Services billed by physician specialties represented 70% of the dollars incorrectly paid for physical therapy services in the November 2011 Comprehensive Error Rate Testing (CERT) Report.

Additionally, past medical review experience has identified high claim error rates when therapy services are billed by physicians.

The most common reasons for an error to be assigned are the following:

• insufficient documentation
• failure to meet Medicare’s documentation requirements specific to physical therapy services
• failure to meet medical necessity guidelines.

Therefore, based on high error rates validated through CERT findings and FCSO’s data analysis, a prepayment medical review edit for physical therapy claims billed by physicians in Florida will be implemented on March 19, 2012.

This prepayment edit will require submission of medical records to support physical therapy services billed by physicians.

More information can be found at the First Coast Service Options web site.

We discussed Medicare Audits here and the high CERT error rate for Chiropractors here.

The comprehensive error rate testing (CERT) and chiropractic services

Billing maintenance therapy as active treatment

First Coast Service Options (FCSO) is estimating an improper payment error rate of 39 percent for chiropractic services in J9 (Florida, Puerto Rico and the US Virgin Islands) for the November 2011 CERT report.

These payment errors often involve the billing of chiropractic manipulation services that represent maintenance care.

Providers’ adherence to Medicare coverage guidelines for chiropractic services continues to be a significant issue in Florida, Puerto Rico, the U.S. Virgin Islands, and the nation.

Based on previous national findings, CMS requested that CERT perform a special study of chiropractic services in 2010. The CERT special study on chiropractic services yielded an overall error rate of 86.91 percent for J9.

The vast majority of the services reviewed were denied for insufficient documentation and for not being medically reasonable and necessary. Aside from documentation issues, the primary reason for payment errors in chiropractic services is maintenance therapy being billed as active treatment. This continues to be an issue, even after CMS implemented an acute treatment modifier to allow providers to differentiate maintenance from active treatment on submitted claims.

To help reduce and prevent improper payment errors, FCSO is reviewing data to identify beneficiaries receiving chiropractic services at routine intervals for extended periods of time and will develop beneficiary specific edits. FCSO will monitor the appeals data closely for these beneficiary specific edits, allowing ongoing edit adjustment when indicated.

Additional information

FCSO has a Web-based training (WBT) module for chiropractic services available on FCSO University . In addition, helpful information and links to chiropractic services resources can be found on the FCSO provider website and the chiropractic services specialty page.

Also, a local coverage determination (LCD) was developed to assist providers in determining when Medicare will consider chiropractic manipulation of the spine medically reasonable and necessary. The LCD also provides guidance on documentation requirements.

To access the LCD for Florida click here, for Puerto Rico and the U.S. Virgin Islands click here.

Chiropractic Services in Florida Have High Error Rate

First Coast Service Options (FCSO) is estimating an improper payment error rate of 39 percent for chiropractic services in Florida for the November 2011 CERT report. These payment errors often involve the billing of chiropractic manipulation services that represent maintenance care.

Providers’ adherence to Medicare coverage guidelines for chiropractic services continues to be a significant issue in Florida and the nation.

Based on previous national findings, CMS requested that the Comprehensive Error Rate Testing (CERT) program perform a special study of chiropractic services in 2012. The CERT special study on Florida chiropractic services yielded an overall error rate of 86.91 percent.

The vast majority of the services reviewed were denied for insufficient documentation and for not being medically reasonable and necessary.

Aside from documentation issues, the primary reason for payment errors in chiropractic services is maintenance therapy being billed as active treatment. This continues to be an issue, even after CMS implemented an acute treatment modifier to allow providers to differentiate maintenance from active treatment on submitted claims.

To help reduce and prevent improper payment errors, FCSO is reviewing data to identify beneficiaries receiving chiropractic services at routine intervals for extended periods of time and will develop beneficiary specific edits.

Here are some additional resources:

• FCSO links page for Chiropractic Services 
• December First Coast Service Options Bulletin 
• Chiropractic Services Checklist

Here is the checklist for chiropractic providers to follow to assure that their services, when properly documented, demonstrate medical necessity for care. This checklist is being provided as a tool to assist providers when responding to medical record documentation requests.

It is the responsibility of the provider of services to ensure the correct submission of all required documentation. Review the following prior to submitting documentation for medical review.

• Please be sure documentation submitted is legible. 
• Please submit records for all dates of service on the claim. 
• Ensure the medical records submitted supports that the service is “Active treatment,” rather than maintenance.
• Ensure the medical records provide justification supporting medical necessity for the service by submission of the following:
• Progress notes 
• Initial and subsequent visits 
• Treatment record including plan of care 
• Abbreviation list 
• Signatures/credentials of professionals providing services 
• Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the additional documentation request (ADR) letter.

This information is relevant to physical therapists because we often treat the sames patients (chronic lower back pain, for example) and we often suffer from the same errors in documentation that chiropractors suffer from.

The Medicare 2010 CERT Report can be found here.

Medicare Discusses New, Unpublished CERT Error Rates Affecting Physical Therapists in Florida

I just sat in on the quarterly Medicare First Coast Service Options (FCSO) Provider Outreach and Education Advisory Group, Part B (POE AG - B) conference call which revealed the newest, unpublished data on physical therapy practices in Florida.

The Medicare TOP PRIORITY for Florida is reducing their CERT error rate which at this time stands at an ALL TIME HIGH of 14.5%.

Most important, the number one cause of this high error rate is INSUFFICIENT DOCUMENTATION.

Specifically, 81% of the CERT error rate was due to one of the following:

1. The written Plan of Care was not included
2. The Progress Notes did not include reasons for continuing therapy.
3. No daily treatment notes
4. No physician certification of the Plan of Care

Physical therapists can improve their documentation using some simple tools:

• Use graphic displays of patient functional progress 
• Use the FCSO Interactive Worksheet to understand what documentation is required for Medically Necessary services.
• Consider additional justification statements when the physical therapy services exceed the initial treatment period, typically one month.