(Medicare Benefit Policy Manual)

Example #5 describes a scenario where a patient on a maintenance program needs intermittent review and possibly a new or revised maintenance program.  EXAMPLE:   A patient who has a progressive degenerative disease is performing the activities in a maintenance program established by a therapist with the assistance of family members.  The program needs to be re- evaluated to determine whether assistive equipment is  needed and to establish a new or revised maintenance program to maintain function or to prevent or slow further deterioration.  Intermittent re -evaluation of the maintenance program would generally be covered as this is a service that requires the skills of a therapist.  Should the therapist conducting the re-evaluation determine that the program needs to be revised, these services would generally be covered.  Maintenance program services that do not meet the criteria of this section are not reasonable or necessary and are not covered under 1862(a)(1)(A) of the Act.   The maintenance program provisions outlined in this section do not apply to the PT, OT, or SLP services furnished in a comprehensive outpatient rehabilitation facility (CORF) because the statute specifies that CORF services are rehabilitative.   220.3 - Documentation Requirements for Therapy Services  (Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)  A.  General   To be payable, the medical record and the information on the claim form must consistently and accurately report covered therapy services, as documented in the medical record.  Documentation must be legible, relevant and sufficient to justify the services billed.  In general, services must be covered therapy services provided according to Medicare requirements.  Medicare requires that the services billed be supported by documentation that justifies payment.  Documentation must comply with all requirements applicable to Medicare claims.   The documentation guidelines in sections 220 and 230 of this chapter identify the minimal expectations of documentation by providers or suppliers or beneficiaries submitting claims for payment of therapy services to the Medicare program.  State or local laws and policies, or the policies or professional guidelines of the relevant profession, the practice, or the facility may be more stringent.  It is encouraged but not required that narratives that specifically justify the medical necessity of services be included in order to support approval when those services are reviewed.  (See also section 220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services)   Contractors shall consider the entire record when reviewing claims for medical necessity so that the absence of an individual item of documentation does not negate the medical necessity of a service when the documentation as a whole indicates the service i s necessary.  Services are medically necessary if the documentation indicates they meet the requirements for medical necessity including that they are skilled, rehabilitative services, provided by clinicians (or qualified professionals when appropriate) with the approval of a physician/NPP, safe, and effective (i.e., progress indicates that the care is effective in rehabilitation of function).  B.  Documentation Required   List of required documentation.  These types of documentation of therapy services are expected to be submitted in response to any requests for documentation, unless the contractor requests otherwise.  The timelines are minimum requirements for Medicare payment.  Document as often as the clinicians judgment dictates but no less than the frequency required in Medicare policy:   Evaluation and 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 recertifications when records are requested after the certification/recertification is due.  See definitions in section 220 and certification policy in section 220.1.3 of this chapter.  Certification (and recertification of the plan when applicable) are 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.  (See definitions in section 220 and descriptions in 220.3 D);   Treatment notes for each treatment day (may also serve as progress reports when required information is included 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 their 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.  Limits on Requirements .  Contractors shall not require more specific documentation unless other Medicare manual policies require it.  Contractors may request further information to be included in these documents concerning specific cases under review when that information is relevant, but not submitted with records.  Dictated Documentation.   For Medicare purposes, dictated therapy documentation is considered completed on the day it was dictated.  The qualified professional may edit and electronically sign the documentation at a later date.   Dates for Documentation .  The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan .  However, contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the progress report or treatment note refers.  For example, if treatment began on the first of the month at a frequency of twice a week, a progress report would be required at the end of the month.  Contractors may require that the progress report that describes that month of treatment be dated not more than 1 week after the end of the month described in the report.   Document Information to Meet Requirements.  In preparing records, clinicians must be familiar with the requirements for covered and payable outpatient therapy services.  For example, the records should justify:   The patient is under the care of a physician/NPP;  Physician/NPP care shall be documented by physician/NPP certification (approval) of the plan of care; and  Although not required, other evidence of physician/NPP involvement in the patients care may include, for example:  order/referral, conference, team meeting notes, and correspondence.   Services require the skills of a therapist.   Services must not only be provided by the qualified professional or qualified personnel, but they must require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently.  A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each progress report period.  In addition, a therapists skills may be documented, for example, by the clinicians descriptions of their skilled treatment, the changes made to the treatment due to a clinicians assessment of the patients needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.   Services are of appropriate type, frequency, intensity and duration for the individual needs of the patient.  Documentation should establish the variables that influence the patients condition, especially those factors that influence the clinicians decision to provide more services than are typical for the individuals condition.  Clinicians and contractors shall determine typical services using published professional literature and professional guidelines.  The fact that services are typically billed is not necessarily evidence that the services are typically appropriate.  Services that exceed those typically billed should be carefully documented to justify their necessity, but are payable if the individual patient benefits from medically necessary services.  Also, some services or episodes of treatment should be less than those typically billed, when the individual patient reaches goals sooner than is typical.  Documentation should establish through objective measurements that the patient is making progress toward goals.  Note that regression and plateaus can happen during treatment.  It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.   Needs of the Patient.   When a service is reasonable and necessary, the patient also needs the services.  Contractors determine the patients needs through knowledge of the individual patients condition, and any complexities that impact that condition, as described in documentation (usually in the evaluation, re-evaluation, and progress report).  Factors that contribute to need vary, but in general they relate to such factors as the patients diagnoses, complicating factors, age, severity, time since onset/acuity, self-efficacy/motivation, cognitive ability, prognosis, and/or medical, psychological and social stability.  Changes in objective and sometimes to subjective measures of improvement also help establish the need for rehabilitative services.  The use of scientific evidence, obtained from professional literature, and sequential measurements of the patients condition during treatment is encouraged to support the potential for continued improvement that may justify the patients need for rehabilitative therapy or the patients need for maintenance therapy.    Functional information included on claims as required.  The clinician is required to document in the patients medical record, using the G -codes and severity modifiers used in functional reporting, the patients current, projected goal, and discharge status, as reported pursuant to functional reporting requirem ents for each date of service for which the reporting is required.  See section 220.4 below for details on documenting G-code and modifiers.  NOTE : Functional reporting and its associated documentation requirements are no longer applicable for claims or me dical records for dates of service on and after January 1, 2019.  See the NOTE  at the beginning of Section 220.4 for more information.    C.  Evaluation/Re-Evaluation and Plan of Care  The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings and subjective patient self-reporting.  Utilize the guidelines of the American Physical Therapy Association, the American Occupational Therapy Association, or the American Speech -Language and Hearing Association as guidelines, and not as policy.  Only a clinician may perform an initial examination, evaluation, re -evaluation and assessment or establish a diagnosis or a plan of care.  A clinician may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evalu ation or re-evaluation.  The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.  Documentation of the evaluation should list the conditions and complexities and, where it is not obvious, describe the impact of the conditions and complexities on the prognosis and/or the plan for treatment such that it is clear to the contractor who may review the record that the services planned are appropriate for the individual.  Evaluation shall include:   A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated.  The diagnosis should be specific and as relevant to the problem to be treated as possible.  In many cases, both a medical diagnos is (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant.  The treatment diagnosis may or may not be identified by the therapist, depending on their scope of practice.  Where a diagnosis is not allowe d, use a condition description similar to the appropriate ICD code.  For example the medical diagnosis made by the physician is CVA; however, the treatment diagnosis or condition description for PT may be abnormality of gait, for OT, it may be hemiparesis, and for SLP, it may be dysphagia.  For PT and OT, be sure to include body part evaluated.  Include all conditions and complexities that may impact the treatment.  A description might include, for example, the premorbid function, date of onset, and current  function;    Results of one of the following four measurement instruments are recommended, but not required:   National Outcomes Measurement System (NOMS) by the American Speech -Language Hearing Association  Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)   Activity Measure  Post Acute Care (AM -PAC)   OPTIMAL by Cedaron through the American Physical Therapy Association   If results of one of the four instruments above is not recorded, the record shall contain instead the following information indicated by asterisks (*) and should contain (but is not required to contain) all of the following, as applicable.  Since published research supports its impact on the need for treatment, information in the following indented bullets may also be included with the results of the above four instruments in the evaluation report at the clinicians discretion.  This information may be incorporated into a test instrument or separately reported within the required documentation.  If it changes, update this information in the re-evaluation, and/or treatment notes, and/or progress reports, and/or in a separate record.  When it is provided, cont ractors shall take this documented information into account to determine whether services are reasonable and necessary.   Documentation supporting illness severity or complexity including, e.g.,  o Identification of other health services concurrently being provided for this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse, respiratory therapy, social services, psychology, nutritional/dietetic services, radiation therapy, chemotherapy, etc.), and/ or   o Identification of durable medical equipment needed for this condition, and/or   o Identification of the number of medications the beneficiary is taking (and type if known); and/or