(Medicare Benefit Policy Manual)

Delayed Reports.   If the clinician has not written a progress report before the end of the progress reporting period, it shall be written within 7 calendar days after the end of the reporting period.  If the clinician did not participate actively in treatment during the progress report period, documentation of the delayed active participation shall be entered in the treatment note as soon as possible.  The treatment note shall explain the reason for the clinicians missed active participation.  Also, the treatment note shall document the clinicians guidance to the assistant or qualified personnel to justify that the skills of a therapist were required during the reporting period.  It is not necessary to include in this treatment note any information already  recorded in prior treatment notes or progress reports.   The contractor shall make a clinical judgment whether continued treatment by assistants or qualified personnel is reasonable and necessary when the clinician has not actively participated in treatment for longer than one reporting period.  Judgment shall be based on the individual case and documentation of the application of the clinicians skills to guide the assistant or qualified personnel during and after the reporting period.  Early Reports.  Often, progress reports are written weekly, or even daily, at the discretion of the clinician.  Clinicians are encouraged, but not required to write progress reports more frequently than the minimum required in order to allow anyone who reviews the records to easily determine that the services provided are appropriate, covered and payable.   Elements of progress reports may be written in the treatment notes if the provider/supplier or clinician prefers.  If each element required in a progress report is included in the treatment notes at least once during the progress report period, then a separate progress report is not required.  Also, elements of the progress report may be incorporated into a revised plan of care when one is indicated.  Although the progress report written by a therapist does not require a physician/NPP signature when written as a stand -alone document, the revised plan of care accompanied by the progress report shall be re-certified by a physician/NPP.  See section 220.1.2C, Changes to the Therapy Plan, for guidance on when a revised plan requires certification.  Progress Reports for Services Billed Incident to a Physicians Service.  The policy for incident to services requires, for example, the physicians initial service, direct supervision of therapy services, and subsequent services of a frequency which reflect his/her active participation in and management of the course of treatment (see section 60.1B of this chapter.  Also, see the billing requirements for services incident to a physician in Pub. 100-04, chapter 26, Items 17, 19, 24, and 31.)  Therefore, supervision and reporting requirements for supervising physician/NPPs supervising staff are the same as those for PTs and OTs supervising PTAs and OTAs with certain exceptions noted below.  When a therapy service is provided by a therapist, supervised by a physician/NPP and billed incident to the services of the physician/NPP, the progress report shall be written and signed by the therapist who provides the services.  When the services incident to a physician are provided by qualified personnel who are not therapists, the ordering or supervising physician/NPP must personally provide at least one treatment session during each progress report period and sign the progress report.   Documenting Clinician Participation in Treatment in the Progress Report.  Verification of the clinicians required participation in treatment during the progress report period shall be documented by the clinicians signature on the treatment note and/or on the progress report.  When unexpected discontinuation of treatment occurs, contractors shall not require a clinicians participation in treatment for the incomplete reporting period.   The Discharge Note (or Discharge Summary)  is required for each episode of outpatient treatment.  In provider settings where the physician/NPP writes a discharge summary and the discharge documentation meets the requirements of the provider setting, a separate discharge note written by a therapist is not required.  The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge.  In the case of a discharge unanticipated in the plan or previous progress report, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified personnel.  In the case of a discharge anticipated within 3 treatment days of the progress report, the clinician may provide objective goals which, when met, will authorize the assistant or qualified personnel to discharge the patient.  In that case, the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist, and services were provided or supervised by a clinician.  The discharge note shall include all treatment provided since the last progress report and indicate that the therapist reviewed the notes and agrees to the discharge.   At the discretion of the clinician, the discharge note may include additional information; for example, it may summarize the entire episode of treatment, or justify services that may have extended beyond those usually expected for the patients condition.  Clinicians should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed.  The record should be reviewed and organized so that the required documentation is ready for presentation to the contractor if requested.   Assistants Participation in the Progress Report.   PTAs or OTAs may write elements of the progress report dated between clinician reports.  Reports written by assistants are not complete progress reports.  The clinician must write a progress report during each progress report period regardless of whether the assistant writes other reports.  However, reports written by assistants are part of the record and need not be copied into the clinicians report.  Progress reports written by assistants supplement the r eports of clinicians and shall include:   Date of the beginning and end of the reporting period that this report refers to;   Date that the report was written (not required to be within the reporting period);   Signature, and professional identification, or for dictated documentation, the identification of the qualified professional who wrote the report and the date on which it was dictated;    Objective reports of the patients subjective statements, if they are relevant.  For example, Patient reports pain after 20 repetitions.  Or, The patient was not feeling well on 11/05/06 and refused to complete the treatment session.; and   Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occur.  Note that assistants may not make clinical judgments about why progress was or was not made, but may report the progress objectively.  For example: increasing strength is not an objective measurement, but patient ambulates 15 feet with maximum assistance is objective.   Descriptions shall make identifiable reference to the goals in the current plan of care.  Since only long term goals are required in the plan of care, the progress report may be used to add, change or delete short term goals.  Assistants may change goals only under the direction of a clinician.  When short term goal changes are dictated to an assistant or to qualified personnel, report the change, clinicians name, and date.  Clinicians verify these changes by co -signatures on the report or in the clinicians progress report.  (See section 220.1.2(C) to modify the plan for changes in long term goals).  The evaluation and plan of care are considered incorporated into the progress report, and information in them is not required to be repeated in the report.  For example, if a time interval for the treatment is not specifically stated, it is assumed that th e goals refer to the plan of care active for the current progress report period.  If a body part is not specifically noted, it is assumed the treatment is consistent with the evaluation and plan of care.  Any consistent method of identifying the goals may be used.  Preferably, the long term goals may be numbered (1, 2, 3,) and the short term goals that relate to the long term goals may be numbered and lettered 1.A, 1.B, etc.  The identifier of a goal on the plan of care may not be changed during the episode of care to which the plan refers.  A clinician, an assistant on the order of a therapist or qualified personnel on the order of a physician/NPP shall add new goals with new identifiers or letters.  Omit r eference to a goal after a clinician has reported it to be met, and that clinicians signature verifies the change.   Content of Clinician (Therapist, Physician/NPP) Progress Reports.  In addition to the requirements above for notes written by assistants, the progress report of a clinician shall also include:   Assessment of improvement, extent of progress (or lack thereof) toward each goal;   Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinicians progress report; and   Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.    Functional documentation is required as part of the progress report at the end of each progress reporting period.  It is also required at the time of discharge on the discharge note or summary, as applicable.  The clinician documents, on the applicable dates of service, the specific nonpayable G-codes and severity modifiers used in the required reporting of the patients functional limitation(s) on the claim for services, including how the modifier selection was made.  See subsection C of 220.4 below for details relevant to documentation requirements.  A re-evaluation should not be required before every progress report routinely, but may be appropriate when assessment suggests changes not anticipated in the original plan of care.   Care must be taken to assure that documentation justifies the necessity of the services provided during the reporting period, particularly when reports are written at the minimum frequency.  Justification for treatment must include, for example, objective evidence or a clinically supportable statement of expectation that:   In the case of rehabilitative therapy, the patients condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a r easonable and generally predictable period of time.   In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patients functional status and the services cannot be safely carried out by the beneficiary him or herself, a family memb er, another caregiver or unskilled personnel.  Objective evidence consists of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome.  Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment.  Such tools are not required, but their use will enhance the justification for needed therapy.  Example:  The Plan  states diagnosis is 787.2- Dysphagia secondary to other late effects of CVA.  Patient is on a restricted diet and wants to drink thick liquids.  Therapy is planned 3X week, 45 minute sessions for 6 weeks.  Long term goal is to consume a mechanical soft di et with thin liquids without complications such as aspiration pneumonia.  Short Term Goal 1:  Patient will improve rate of laryngeal elevation/timing of closure by using the super-supraglottic swallow on saliva swallows without cues on 90% of trials.  Goal 2:  Patient will compensate for reduced laryngeal elevation by controlling bolus size to  teaspoon without cues 100%.  The progress report for 1/3/06 to 1/29/06 states:  1.  Improved to 80% of trials; 2. Achieved.  Comments:  Highly motivated; spouse assists with practicing, compliant with current restrictions.  New Goal: 5.  Patient will implement above strategies to swallow a sip of water  without coughing for 5 consecutive trials.  Mary Johns, CCC-SLP, 1/29/06.  Note the provider is billing 92526 three times a week, consistent with the plan; progress is documented; skilled treatment is documented.   E.  Treatment Note   The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim.  Documentation is required for every treatment day, and every therapy service.  The format shall not be dictated by contractors and may vary depending on the practice of the responsible clinician and/or the clinical setting.  The treatment note is not required to document the medical necessity or appropriateness of the ongoing therapy services.  Descriptions of skilled interventions should be included in the plan or the progress reports and are allowed, but not required daily.  Non-skilled interventions need not be recorded in the treatment notes as they are not billable.  However, notation of non- skilled treatment or report of activities performed by the patient or non-skilled staff may be reported voluntarily as additional information if they are relevant and not billed.  Specifics such as number of repetitions of an exercise and other details included in the plan of care need not be repeated in the treatment notes unless they are changed from the plan.  Documentation of each treatment shall include the following required elements:   Date of treatment; and    Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding.  Record each service provided that is represented by a timed code, regardless of whether or not it is billed, because the unbilled timed services may impact the billing; and