Presented by
Pauline M. Franko, PT, CEEAA
FPTA Conference
Friday, September 12th 2014
Presenter:
Pauline M. Franko, PT, CEEAA FL License # 3174
Pauline is president and CEO of Encompass Consulting & Education, LLC created in
2014. She also authors the “Medicare Advisor” columns for the Advance for Physical
Therapists and Rehabilitation Medicine newsmagazine.
She graduated from Physiotherapy School in Coventry, England in 1966 and came to
the US in 1980. Her experience has always been in the area of geriatrics, including SNF,
Home Health, CORF and long term care rehabilitation administration. During her time
as a Regional Manager for a Long Term Care Company she became interested in the
area of Medicare Compliance. Pauline and another physical therapist, Danna D. Mullins
PT, MPT, established Encompass Education Inc. in 1999 to educate therapists on the
rules and regulations for Medicare Compliance. During this time she also became the
Director of Medicare Compliance and Education for a CORF In May 2004 that
Encompass Education was dissolved and Pauline established Encompass Consulting &
Education LLC.
In 2011 she was Certified as an Exercise Expert for the Aging Adult by the APTA. As
well as presenting seminars and webinars for Encompass, she has presented nationwide
including the annual conference of the APTA and State Associations as well as for other
therapy organizations.
Encompass Consulting & Education, LLC © 2014 1
Welcome to Surviving a Manual Medical Review
OBJECTIVES
1. Describe the four categories of non-
compliance that can lead to a denial
2. Distinguish between the different types of
Medical Review and who performs them
3. Define Medicare's Medical Necessity
Requirements for therapy services
4. Understand the top reasons for denials and
identify areas of their practice that need revision
THE WHAT IS:
Hands-on review of copies of the medical
record and other relevant documentation by a
qualified medical professional
Contractor sends an Additional Documentation
Request (ADR)
Identifies what documentation required and
what date due
Timeframe varies by contractor type
THE WHY IS:
“To determine if claims submitted for
payment were billed in compliance with
Medicare Regulations for that particular site
of service”
In Medicare’s other words - Was the claim
billed in “error”?
AN ERROR OCCURS WHEN THE
SERVICES PROVIDED:
Are excluded by Medicare
Do not meet the benefit category
Not billed in compliance with LCD or NCD
Are not reasonable and necessary
EXCLUDED BY MEDICARE
PT, OT and SLP are Medicare covered services in all sites of service:
• Acute: Hospitals
• Post-acute: SNF and Home Health
• Part B in hospital and other settings
Part B is a capitated service and can become an excluded benefit
NOT A BENEFIT CATEGORY
Each site of service has “Conditions of Coverage” criteria which must be met for payment.
Once beneficiary does not meet the requirements for coverage, it becomes a non-covered benefit category for that site
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Conditions of Coverage
CONDITIONS OF COVERAGE -
TECHNICAL COMPONENTS
Must be met or the
claim will be denied
AND
is non-appealable
Medicare beneficiary with usable days
Qualifying 3 days hospital stay
Admitted to within 30 days from hospital D/C
Certification and Recertification by
Physician or NPP for the need of the stay
TECHNICAL COMPONENTS FOR PART
A SNF
Beneficiary must be confined to the home
Under the care of a physician
Receiving services under a POC
established and periodically reviewed by a
physician
TECHNICAL COMPONENTS FOR A
HOME HEALTH AGENCY
CONDITIONS OF COVERAGE -
CLINICAL COMPONENT
Each Part A provider setting
has different criteria
Always the same criteria for
Therapy whether A or B
1. CONDITION TREATED IN
HOSPITAL
Services are provided for a condition treated in hospital or occurred during SNF care for that condition
“In this context, the applicable hospital condition need not have been the principal diagnosis that actually precipitated the beneficiary’s admission to the hospital, but could be any one of the conditions present during the qualifying hospital stay.”
IOM Pub 100-02 Chapter 8 (Rev. 161, Issued: 10-26-12, Effective: 04-01-13, Implementation: 04-01-13)
2. DAILY SKILLED SERVICES
Needs and receives daily skilled nursing and
/ or rehab (at least 5 separate days of rehab
services)
“However, arbitrarily staggering the timing
of various therapy modalities though the
week, merely in order to have some type of
therapy session occur each day, would not
satisfy the SNF coverage requirement for
skilled care to be needed on a “daily basis.”
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3. INPATIENT BASIS AS A
“PRACTICAL MATTER”
Only available in SNF if not available in the
area the resident resides or transportation
to the nearest facility would:
Be an excessive hardship
Less economical
Less efficient or effective than the SNF
PRACTICAL MATTER
As a Practical Matter can only be provided on inpatient basis
“This requirement should not be applied so strictly that it would not be met merely because there is an isolated break of a day or two during which no skilled rehabilitation services are furnished and discharge from the facility would not be practical.”
In need of skilled nursing care on an
intermittent basis
and / or PT
and / or SLP
or
Have a continuing need for OT
HOME HEALTH CLINICAL
COMPONENT
TECHNICAL COMPONENT OF
PART B THERAPY SERVICES
Physician
Certification of
Need
IOM Pub. 100-02, Benefit Manual:
§220.1.3
METHOD AND DISPOSITION
OF CERTIFICATIONS
Certification Requires:
A dated signature on the plan
Or
Some other document that indicates
approval of the plan
The date is required to determine if the
certification is timely!
TIMELY CERTIFICATIONS
The plan is reviewed and approved by the
Physician or Non Physician Practitioner
(NPP) within 30 days from the initial
treatment/evaluation
Physician Certification satisfies all
certification requirements for the
a) duration of the plan or
b) 90 calendar days from the initial treatment
whichever is less
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Medical Necessity
DELAYED CERTIFICATION
IOM Pub. 100-02, Benefit Manual: §220.1.3D
Delayed Certification:
Delayed certification/recertification shall be
deemed satisfied where, at any later date,
a physician/NPP makes a certification
accompanied
by a reason for the delay.
NOT BILLED IN COMPLIANCE WITH
NCD & LCDS
CMS publishes NCDs of services they will not cover, e.g. Anodyne therapy
Medicare Administrative Contractors (MACs) publish their own LCDs
LCDs are contractor specific
Provider must follow guidelines or claim can be denied
NOT REASONABLE AND
NECESSARY
Guidelines apply to all sites of service
Must be clearly identified in documentation
If not, claim WILL BE denied
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Medical Record Reviewers
“MEDICAL NECESSITY” DOES
NOT OCCUR WHEN
A pt suffers a transient and easily reversible
loss or reduction of function (e.g. temporary
weakness which may follow a brief period of
bed rest following abdominal surgery) which
could reasonably be expected to improve
spontaneously as pt gradually resumes
normal activities.
ZONE PROGRAM INTEGRITY
CONTRACTORS: ZPICS
Work with specific MACS
Responsible for monitoring all
Federal Programs
Became most aggressive
contractor
Performing reviews in States
with high level of fraud and
abuse
MEDICARE ADMINISTRATION
Department of Health & Human Service
Centers for Medicare & Medicaid
Contractors
• Medicare Administrative Contractors
• Safeguard contractors
A/B MAC RESPONSIBILITIES
Also Responsible
for
Provider enrollment
Level 1 appeals
Outreach &
Education
Reimbursement
Medical Review
LCD
Receive, Process & Pay Medicare A and B claims
SAFEGUARD CONTRACTORS
RESPONSIBILITIES:
Fraud Detection
and Prevention
Data Mining and
Analysis
Manual Medical Review
RECOVERY AUDITORS: RACS
Professional Collection Companies
4 Contractors cover 4 separate regions
Paid on % of monies recouped
Predominately focused on Hospital and Physician claims
Effective April 1st, became sole review source for Manual Medical Review above the $3700 threshold
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Types of Medical Review
COMPREHENSIVE ERROR RATE
TESTING CONTRACTORS: CERT
Perform random post-pay reviews
Monitors: All providers, suppliers and practitioners
MACs
CMS
Report directly back to MACs on common review denials in their region
Publish an Annual Report
SUPPLEMENTAL REVIEW
CONTRACTOR – THE NEW KID
Strategic Health Solutions: works for CMS
assisting MLN produce easy to understand
information
Now also performing MMR as instructed by
CMS
Reviewing OPT claims between 7/12 & 3/13
Focus: therapy stopped or delayed prior to
reaching the $3700 cap
TYPES OF MEDICAL REVIEW
Pre-pay or Post-pay Review
Simple
Automatic
Complex/MMR
Probe
GlobalProvider Specific
Random
SIMPLE REVIEWS
Claims Review
Looking for inappropriate charges
• Billing more than 1 unit for non-time sensitive codes
• Billing multiple re-evaluation codes
Review may lead to a complex review
PROBE REVIEWS
Developed on analysis of patterns of claims
Normal Practice Patterns
Yours Statewide National
Notification letter not required
Notification letter required
GLOBAL PROBE VS PROVIDER
PROBE
General probe of
several providers
Limited to 100
claims per review
Initially 20 to 40
claims reviewed
Individual provider
issue
Global Probe Provider Probe
Error rate and prior history will determine
next level of review
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PROBE REVIEWS
Any aberrances from the norm
Potential areas of over-utilization
Use of high paying CPT or RUG codes
Length of Stay
Patterns of non-covered care
Use of ICD-9 codes –especially V-codes
Use of KX modifier
PRE-PAY MEDICAL REVIEW
Ending the pay & chase
Using sophisticated
“Data Mining” tools
Becoming preferred method of review in
some states
THRESHOLD REVIEWS
CMS assigned the RACs to perform these reviews
Current RAC contracts are up for review
February 28th last day for ADRs
Claims from March 1st on hold
August 4th CMS awarded restricted contracts to current RACs to start limited MMRs
Therapy Services included
PART B CAP-SPECIFIC MMR
HIGH FRAUD RATE
FL
CA
MI
TX
NY
LO
IL
SHORT STAYS
PA
OH
NC
MO
SEQUENCE
Claim received by MAC
MAC issues ADR
Records sent to
RAC
RAC reviews in 10
business days or less
RAC sends findings to MAC, letter to provider
MAC Adjudicate response
PROGRESSIVE CORRECTIVE
ACTION - PCA
Data Collection
and Analysis
Medical Review
of Claims
Provider Education on
Requirements for Payment
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OVERALL REVIEW PROCESS
ADR sent
Provider sends documentation
Documentation checked for completeness
Reviewed for accuracy of items billed
Reviewed for medical necessity
Provider Notified of negative findings
IMMEDIATE DENIALS
Documentation does not arrive timely
• Timeframe identified on ADR
Insufficient documentation
Documentation is illegible
• Reviewer cannot read it
• Reviewer cannot understand it
Signatures are illegible
ACCEPTABLE SIGNATURES
Hand written signatures
Electronic signatures
Signature Log
BUT NEVER a stamped signature
LEGIBLE SIGNATURES ARE
Legible full signature
Legible first initial and full last name
Initials placed above a typed or printed name
Illegible signature placed above a typed or
printed name
Illegible signature where other information on
the page identifies signor
Illegible signature accompanied by a signature
log
REVIEW CONSIDERATIONS - SNF
Do Diagnosis(es) support use of therapy
Do: Dates billed support skilled days used
Does: Documentation support RUG(s) billed
Does: Documentation support Medical Necessity for Site of Service
REVIEW CONSIDERATIONS –
PART B
Does: Diagnoses support therapy intervention
Do: Dates of treatment match claim
Are: CPT codes supported by documentation
Do: Units billed match time documented
Are: Modifiers used appropriate
Does: Documentation support Medical Necessity
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Progressive Corrective Action
WHAT HAS BEEN LEARNED
FROM MMR
The regulations
are standard
The reviewers
interpretations
are NOT
CERT CONTRACTOR
Insufficient Documentation
Did not arrive in time
Was illegible
No documentation for date of service
Too many abbreviation for reviewer to understand
Services Coded Incorrectly
Units billed not substantiated by documentation
Documentation does not support skilled treatment
(interventions not clearly identified to support codes billed)
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Reasons for Denials
CERT CONTRACTOR
Medically Unnecessary Services
Treatment provided not supported by Plan
No documentation of physician approval of Plan
Treatment provided after last day approved by physician
Documentation appears repetitious with no change in
treatment
No documentation of progress in a reasonable period of time
Duplication of services
CAP THRESHOLD DENIALS
Not submitting therapy records
No POC or evidence of physician approval
(certification)
Goals not measurable
Services maintenance in nature
Already having lots of time in therapy
CAP THRESHOLD DENIALS
Inadequate prior level of function
Documentation missing elements to substantiate
medical necessity for additional services
Unable to determine functional deficit
NOTIFICATIONS FROM A RAC
“Review of Medical Record does not show
sufficient documentation supporting services
provided and medical necessity for therapy
amount, frequency & duration of physical
therapy services delivered on XX for code
97140”
“
NOTIFICATIONS FROM A RAC
“Documentation … insufficient in identifying
rationale for use of manual therapy
intervention….does not indicate…patient
response to treatment or benefits obtained
to support the use of this procedure”
NOTIFICATIONS FROM RACS
“Documentation supports….provision of
repetitive exercises and functional activities
with no clear complexity of service that
indicate a need for ongoing skilled clinician care
or input, no verbal tactile cueing was noted”
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Documenting Skilled Therapy
NOTIFICATIONS FROM RACS
“Documentation indicates the same exercises
and/or functional activities are being
performed daily with no clear complexity of
services that indicate the need for ongoing
skilled clinician input, i.e. no ongoing
progressive instruction or verbal/tactile
cueing was noted.
NOTIFICATIONS FROM RACS
“The professional skills of a therapist are not
required to improve or restore full function
that could reasonably be expected to
improve as the patient gradually resumes
normal activities. There are no additional
medical complexities noted that would inhibit
the patient from progressing on her own.”
NOTIFICATIONS FROM RACS
“Medical record does not show sufficient
documentation supporting the services provided for
XXX for CPT codes 97110, GO283 and 97140. The
patient has been seen for 3 months after shoulder
surgery. At the time of review the patient continues to
have ongoing functional difficulties including
reaching items in cupboard, donning seatbelt etc.
The patient has made little progress especially in the
last month. There is no change in the POC or focus
on the specific activities she is having difficulty
with. The exercise and treatment plan are repetitive
with no change especially when progress seems to
have slowed or plateaued.”
NOTIFICATIONS FROM RACS
“Additional documentation is needing regarding why a clinician was required to provide the care or reasoning behind the decline that would warrant skilled care.
Documentation for an exception should indicate how the patient’s medical complexity directly and significantly affects the treatment for a therapy condition and the medical necessity of ongoing care. Services that exceed those typically billed should be carefully documented.
In summary the medical record does not show sufficient documentation to support the services provided and medically necessary for the physical therapy services on XXX for 97110, GO283 and 97140.”
SURVIVAL TACTICS:
Documenting Skilled Therapy
Work on Quality of
Documentation
MANDATORY
DOCUMENTATION
Part A:
Very few guidelines
Identified in Code of Federal Regulations
Standardized by industry practice
Part B:
Extremely specific guidelines
Identified in CMS IOM Pub.100-02, Chapter 15
Completely updated in 2005 with updates in 2007, 2009 and 2013
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MANDATORY DOCUMENTATION
Evaluation and Plan of Care / Treatment
(Can be 1 document or 2 separate
documents)
Evidence a physician / NPP has reviewed and
approved the plan (certification)
Daily documentation to support time billed and
skilled services provided
Progress Reports and Discharge Note
USE OF TEMPLATES IN PROGRESS
NOTES
March 2013: CMS updated IOM 100-08 -
Program Integrity Manual - to clarify what
reviewers will consider during Manual
Medical Review
Chapter 3: §3.3.2.1 - Documents on Which to
Base a Determination addresses use of
templates in progress notes.
CHANGE REQUEST 8033
CMS does not prohibit use of templates to
facilitate record-keeping
CMS does not endorse or approve any particular
templates
Some templates provide limited options and/or
space for collection of information such as using
“check boxes,” predefined answers, limited
space to enter information, etc.
CMS discourages the use of such templates
CHANGE REQUEST 8033
Claim review experience shows that limited
space templates often fail to capture sufficient
detailed clinical information to demonstrate
that all coverage and coding requirements are
met:
Templates designed to gather selected
information focused primarily for
reimbursement purposes are often insufficient
to demonstrate that all coverage and coding
requirements are met
CHANGE REQUEST 8033
This is often because these documents generally
do not provide sufficient information to
adequately show that the medical necessity
criteria for the item/service are met
When choosing to use a template during patient
visit, CMS encourages selection of one that
allows for a full and complete collection of
information to demonstrate that applicable
coverage and coding criteria are met
SKILL DIFFERENCES BETWEEN PART
A AND PART B
Remember! Only difference between A and B is the Conditions of Coverage
Documentation focuses on
SNF A: Medical necessity of services supporting need for treatment 5 or more day a week
Part B: Medical necessity of services supporting a need for treatment
For Both: Identification of skilled services that cannot be provided by family or caregiver
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Connecting the Dots - Evaluation
COLOR LEGEND
Level of Function / LTG / DC plans
Impairment
Diagnoses / Complexity
Tests and Measures
Treatment Interventions / Skilled therapy
Information
THE REVIEWER NEEDS TO SEE
Prior
Function
Change
Impairments
Tests &
Measures
Skilled
Therapy
Return
ANSWERS THE QUESTION
Is there a problem?
Evaluation:
EVALUATION ESTABLISHES
Current Level of Function < Prior Level of
Function
Patient History including: Current Medical and Psychosocial History as well as Relevant Medications
Impairments quantified by Tests and Measures leading to an Impairment based Treatment Diagnosis and Onset Date
Discharge Plan
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CLOF AT START OF CARE
Current Level of
Function
answer the
question
“Why are you
here?”
PLOF AT START OF CARE
Prior Level of Function
answers the
questions
What were you able to do that you
can’t do now ?”
How long ago since you did it?
(onset date)
WARNING!
Reviewers are looking at prior level of function more intensely to determine the medical necessity of treatment
The more complete the better!
PSYCHOSOCIAL HISTORY
Where does the patient live?
What barriers are within the home?
Who do they live with?
What responsibilities do they have?
Do they have any one to help them?
MEDICAL HISTORY
CHF / COPD
Obesity
Osteoporosis
Diabetes
Alzheimer's Disease
Renal Failure
Hearing loss
Chronic Wounds
Malnutrition
Vestibular disorders
Depression
Rheumatoid Arthritis
Glaucoma and Low Vision
Cancer
Co-morbidities / Complexities that impact
on and are pertinent to the Plan of Care
MEDICAL HISTORY
What treatment has been done by physician?
Actual treatments (surgery, various medication
changes)
X-rays, CAT scans or MRIs
Lab work results
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Impairments & Measurements
RELEVANT MEDICATIONS
What medication is the patient taking?
Prescribed
(Additional For Part B)
Over the counter
Herbal medication or
supplements
Non-prescribed!!!!!!!!
MEDICAL HISTORY
What Rx has been done by therapy for same or
other conditions
Hospital
SNF
HHA
Other Part B therapies
Your therapy department
What’s causing the
problem?
Impairments and
Measurements:
ANSWERS THE QUESTION
Impairments
Quantify impairments
Identify impairments
Treat impairments
Restore or Improve Function
OBJECTIVE TESTS AND
MEASURES
Must quantify identified impairment(s) to be
treated as well as co-morbidities/complexities
affecting POT
Use accepted standardized tests and measures and /
or
Use functional assessment scores with
subjective patient self report
Use patient questionnaires
SURVIVAL TACTICS:
All relevant impairments must have an
objective test, measure or assessment to
quantify them
Treatment strategies must relate to
impairments identified as a result of the
diagnosis and/or condition and/or
complexity
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Connecting the Dots – Plan of Care
What am I going to do
about it?
Plan of Care:
ANSWERS THE QUESTION
DOCUMENTATION REQUIREMENTS
CFR §424.24, 410.61
Plan shall contain at a minimum:
• Diagnosis;
• Long term treatment goals; and
• Type, amount, duration and frequency of
therapy services
INTERVENTIONS, PROCEDURES,
TECHNIQUES
Identify skilled services therapist will provide
They are NOT CPT codes or code descriptors
When clearly defined in the plan, do not have to be repeated each time in the daily note
e.g. parameters of a modality – e-stim to paraspinals L1 thru L5 for 15 minutes at X intensity to increase circulation & decrease pain
INTERVENTIONS, PROCEDURES,
TECHNIQUES
Are specific treatment strategies
Along with the specific areas / body part to be treated (joints; muscle groups etc.)
Must: Correlate with the impairments identified in the evaluation
e.g. stretchings & soft tissue mobilization techniques to L knee joint to reduce muscle spasms and pain and increase mobility
TYPES OF GOALS
Long Term Functional Goals:
Final outcome level
Short Term Goals:
Stepping stones to LTG
Impairment Goals:
Therapist’s treatment objectives
Diagnoses! Different meanings
for different circumstances
Coding / Billing
(ICD-9 codes)
Medical
Review
Criteria
(IOM Manuals
and LCD)
Medicare
Documentation
(condition being
treated)
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DIAGNOSIS FOR DOCUMENTATION
Is: The condition for which you are rendering
skilled therapy services
Can be: Description of the specific problem be
evaluated / treated (impairment based
treatment diagnosis)
May: Include medical diagnosis provided by
the physician
Is not: An ICD-9 code
DIAGNOSIS FOR CODING / BILLING
First listed diagnosis on the claim form:
Is: The ICD- 9 code that is chiefly responsible
for the services provided.
Can: Be symptom, sign or ill-defined condition
Can: Be a V-code
Other diagnoses on the claim
Are: Treatment diagnoses / conditions /
complexities that impact on the POT
DIAGNOSIS FOR MEDICAL REVIEW
ICD-9 code: Is not excluded through
Local Coverage Determinations (LCD)
Claim will be returned
ICD-9 code: On claim accurately
reflects documented diagnosis(es)
supporting Medical Necessity
Medical Diagnosis: (R) humeral
fracture with ORIF onset
06/01/2012
Conditions Being Treated: Painful
(R) shoulder with decreased ROM
and muscle strength, muscle
spasms resulting in reduced ability
to perform ADLs
DIAGNOSIS: WHICH ONE TO USE?
AMOUNT, FREQUENCY AND
DURATION
Must: Reasonable based on data collected
during assessment / evaluation
Clinician must: Determine appropriate levels
based on evaluation
Should: Change throughout episode based on
patient response
For POT is: Number of times per day treatment
provided, if not stated assumed to be once
Can: Be BID when appropriate (dementia
patients / severe medical conditions)
Is also: Total daily treatment provided
Should: Change throughout the episode of care
based on patient response
AMOUNT OF TREATMENT
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Connecting the Dots – Daily Notes
For POT is: The number of times type of
treatment is to be provided
Part B: Can be tapered: To improve outcomes
and limit treatment time
Tapered treatments may: Result in better
outcomes, or earlier D/C than routine treatment
3 X week for 4 weeks
No requirement for: Exact number of
treatments
FREQUENCY OF TREATMENT
Require: Planned beginning and ending
frequency
e.g. “3 times a week tapered to once a
week over 6 weeks”
Changes: Should be made based on the
clinician’s assessment of daily progress
TAPERED FREQUENCY: PART B
Can: be number of days / weeks /
treatments for this specific POT or
If care anticipated to exceed 90 days
clinician can estimate entire duration in this
setting
Should never be a range
DURATION OF TREATMENT
What skilled services did
I provide and how long
did it take?
Daily Treatment Notes:
ANSWER THE QUESTION
Must: Be written for every day patient is seen
AND identify every therapy service provided
Must: Record the time of services to justify
billing codes (both RUG and CPT codes)on
claim
Format: Shall not be dictated by Contractor
AND may vary depending on responsible
clinician or clinical setting
DAILY TREATMENT NOTES
IDENTIFICATION
Patient Name
Date of treatment
Legible signature of qualified professional
with professional identification
Recommendation:
Include patient MR number or other identifier
Do not include Medicare number or other confidential information
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SKILLED TREATMENT
Reviewers want to see what YOU are doing, not
just patient’s exercise log or equipment print
out
Document your actions
Your thought process
Changes you determine are necessary to
progress patient through your plan
SOME SKILLED WORDS
Analyze
Assess
Adjust
Modify
Adapt
Instruct
Upgrade
Progress
Incorporate
Redirect
Reassess
Compensatory training (specify)
Fabrication
Inhibit
Instruct in (specify)
Model
Normalized
Facilitated
Reduced
Anticipate
Training in task segmentation
SKILLED PHRASES
Transfer training:
Facilitate forward weight shift
Teach concentric/eccentric control during sit to stand
Bed Mobility
Trained pt in rolling onto unaffected side by facilitating trunk rotation
Instructed pt in log rolling technique to reduce exacerbation of muscle spasm during bed rolling & supine to sit activites
SKILLED PHRASES
Pt trained in concentric/eccentric control
during sit to stand
Pt educated in techniques to promote
forward weight shift during sit to stand
transfers
Instructed and trained pt in stepping
strategies to self-correct balance
Facilitated co-contraction during stance
phase
NON-SKILLED PHRASES
Ambulated xxx ft
Patient performed ROM exs
Patient practiced fine motor activities
Decreased physical assistance
Modalities as appropriate
Stair climbing
DOCUMENTATION FLOW FOR
PART B
Allocation of Units
What you did that was skilled
Total and Direct Treatment Time
Identification of CPT Codes
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Connecting the Dots – Progress Reports
Is the treatment working and
the patient improving?
Progress Reports:
ANSWER THE
QUESTION
PROGRESS REPORTS
What the reviewer needs to see:
Evidence that skilled services have been
provide
Progress towards goals is significant in
relation to pt’s condition and co-morbidities
Changes in objective measures are
occurring in response to treatment
Has been written by the clinician and
clinician has provided at least 1 billable
treatment during the progress report period
PART A PROGRESS REPORTS
Federal statutes and CMS provide no guidelines for timing
Generally dictated by Facility Policy
Can be written by therapist or therapist assistant if State Practice Act or State statutes allows
Justify Medical Necessity of both prior and continued treatment
Legible signature with professional designation and date written (date does not have to be within the reporting period)
PART B PROGRESS REPORTS
Must: Be written by the therapist at least once
every 10th treatment day
Justify Medical Necessity of both prior and
continued treatment
Require a beginning and end date of reporting
period
Legible signature with professional
designation and date written (date does not
have to be within the reporting period)
PROGRESS REPORTS
Documentation must clearly identify:
Clinical assessment of overall progress (or
lack) towards each long term goal
Changes in objective tests / measures
(comparison with last progress report)
STGs achieved and updates established
Plans for focus of continued treatment and / or
changes made or to be made to treatment plan
PROGRESS REPORTS
Documentation must clearly identify:
Update to functional reporting and severity
codes:
If goal met and code discharged, new
functional reporting code can be established
along with severity modifier and be reported
in the next treatment note along with method
of selection
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BASIS OF SKILLED PHRASES
Pt continues to demonstrate noticeable
improvement in (Function) with increase in
(objective measure) from (last measure/score) to
(current measure/score) from last report
Pt has received training / education/ instruction
in (skilled technique) but still requires (skilled
technique) due to (impairment)
BASIS OF SKILLED PHRASES
Pt has achieved STG 2c (describe goal) and
new goal STG2d (describe goal) has been
established
Skilled treatment will continue to focus on
(task performance / impairment) with
emphasis on (skilled technique / objective
measure)
LACK OF PROGRESS
Identify problems causing lack of
progress.
Modify Treatment
Assess Response
Re-evaluate if lack of progress
continues
SURVIVAL TACTICS:
Create a Compliance Program
and
Institute an Audit System to
include claims review
SURVIVAL TACTICS:
Initial Emphasis on
Legibility
Certification
Completeness of documentation
Billing Compliance
Knowing and following Medicare coverage and
billing guidelines.
Knowing and following local coverage determinations
(LCDs)
Remain aware of new / changed policies
Ensure that correct bills are
submitted
Submitting all necessary paperwork requested in
timely manner
Survival Tactics:
Encompass Consulting & Education, LLC © 2014 22
Physical Therapy – Skilled Documentation Examples:
Assessed energy expenditure during activities thru observation & monitoring of vital signs
and use of Borg RPE measure
Pt educated in techniques to promote adequate forward weight shift during sit to stand
transfers
Pt trained in safe manipulation of lower extremities during car transfer
Pt trained in selective movement control to reduce/eliminate LE flexion synergistic patterns
Facilitation to initiate & sustain co-contraction of quads/hamstrings
Pt assessed for and trained in functional stride length during gait
Pt trained in appropriate gait sequencing utilizing PNF patterning
Trained pt in safe maneuvering & walker placement in ambulating around obstacles
Trained pt in rolling onto unaffected side by facilitating trunk rotation
Pt trained in diaphragmatic breathing emphasizing relaxed expiration to minimize SOB during
activities
Educated and trained pt in low velocity weight shifts to develop awareness of limits of stability
Instructed and trained pt in stepping strategies to self-correct balance
Facilitated forward weight shift
Educated pt in concentric/eccentric control during sit to stand
Facilitate co-contraction during stance phase
Strengthening exercises to quads and hamstrings to facilitate transfers
Instruction in strengthening exs to bilateral quads, emphasis on achieving terminal extension
of knee and facilitation of vastus medialis thru stroking & tapping
Slow stretching (L) hamstring utilizing contract relax technique
Transfer training with emphasis on maintaining center of gravity over base during hip
extension phase
PNF patterning to bilateral LEs with emphasis on achieving knee extension with hip flexion
Observed and assessed HR, RR and RPE during training in home exercise program
Instruction in scooting forward in chair utilizing alternating hip hiking and contralateral weight
shift
Manual resisted exercises to (R) quads, utilizing quick stretch techniques