Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)

Examples, based on the patients need, may include:mobility status (transfers, bed mobility, gait, etc);self-care dependence (toileting, dressing, grooming, etc);meaningful ADLs/IADLs;pain, and how it limits function; andbalance.Objective impairment testingTesting done to determine the source or cause of the functional limitation(s), such as ROM, manual muscle testing, coordination, tone assessment, balance etc.Use concise, objective measurements. Avoid minimal/moderate/severe types of descriptions when more specific definitions or measurements are available. For example, when measuring shoulder flexion AROM, document degrees of motion, rather than documenting, Shoulder flexion: minimal loss of motion.AssessmentSummary of the therapists analysis of the condition being evaluated based on the examination of the patient. Clinical reasoning for treatment should be evident when further therapy is recommended.Prognosis for return to prior functional status, or the maximum expected conditioPlan of care (see paragraph below)Signature and credentials of the therapist or physician/NPP completing the initial evaluation and plan of care.Each therapy discipline must have a separate plan of care. The plan of care (POC) must contain ALL of the following information.Required POC ElementAdditional PointsDiagnosisThe diagnosis should be specific and as relevant to the problem being treated as possible. In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.Bill the most relevant diagnosis. As always, when billing for therapy services, the ICD-10 code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason. For example, when a patient with diabetes is being treated for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible in accordance with State and local laws and the contractors Local Coverage Determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position.Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.Long Term Goals (LTGs)LTGs should:pertain to the functional impairment findings documented in the evaluation;reflect the final level the patient is expected to achieve as a result of therapy in the current setting;be realistic, and should have a positive effect on the quality of the patients everyday functions;be function-based and written in objective, measurable terms with a predicted date for achieving the goals.Type of TreatmentThe type of treatment includes the type of therapy discipline operating under this POC (PT or OT) and should describe the types of treatment modalities, procedures or interventions to be provided.Amount of TreatmentRefers to the number of times in a day the type of treatment will be provided. Where not specified, one treatment session a day is assumed.Treatment provided more than one session per day per discipline will require additional documentation to support this amount of therapy.Frequency of TreatmentRefers to the number of times in a week that the type of treatment is provided.Treatment more than two or three times a week is expected to be a rare occurrence. Treatment frequency of greater than three times per week requires documentation to support this intensity.Duration of TreatmentRefers to the number of weeks, or the number of treatment sessions, for this plan of care.Clinicians could also estimate the duration of the entire episode of care in this setting.Re-evaluationsRe-evaluation documentation must include clear justification for the need for further tests and measurements after the initial evaluation, such as new clinical findings, a significant, unanticipated change in the patients condition, or failure to respond to the interventions in the plan of care. It is expected that clinicians continually assess the patients progress as part of the ongoing therapy services. This assessment is not considered a formal re-evaluation; the time of any assessment is included and billed within the appropriate treatment intervention CPT code.Re-evaluations must be performed by clinicians and contain all applicable components of the initial evaluation. Resolved problems do not need to be re-evaluated; new or ongoing problems may need to be re-evaluated, especially if there is an anticipated change to the long term goals.Progress ReportsProgress reports provide justification for the medical necessity of treatment. Progress reports shall be written by a clinician at least once every 10 treatment days or at least once every 30 calendar days, whichever is less. Writing progress notes more frequently than the minimum is encouraged to support the medical necessity of treatment. A progress report is not a separately billable service.In CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, sections 220-230, Medicare defines the minimum REQUIRED elements of a progress report. It is essential that clinicians include all required elements in their documentation (either in a progress report or treatment note).Progress note elements include(CMS required elements are italicized): ? Date of the beginning and end of the reporting period that this report refers to;Date that the report was written by the clinician, or if dictated, the date on which it was dictated;Objective reports of the patients subjective statements, if they are relevant;Objective measurements (impairment/function testing) to quantify progress and support justification for continued treatment;Description of changes in status relative to each goal currently being addressed in treatment. Descriptions shall make identifiable reference to the goals in the current plan of care;Assessment of improvement, extent of progress (or lack thereof) toward each goal;Plans for continuing treatment, including documentation of treatment plan revisions as appropriate;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;Signature with credentials of the clinician who wrote the report.No specific format is required to demonstrate patient progress as long as all information noted in the bullets above are included at least once in the medical record for each progress report period (10 treatment days or 30 calendar days, whichever is less). Progress report information may be included in the treatment notes, progress reports and/or formal re-evaluations (when re-evaluation guidelines are met).During each progress report period, the clinician must personally furnish in its entirety at least one billable service on at least one day of treatment. Verification of the clinicians treatment shall be documented by the clinicians signature on the treatment note and/or progress report.Treatment NotesMedical record documentation is required for every treatment day, and every therapy service to justify the use of codes and units on the claim.The treatment note must include the following required information:date of treatment;identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;record of the total time spent in services represented by timed codes under timed code treatment minutes;record of the total treatment time in minutes, which is a sum of the timed and untimed services;signature and credentials of each individual(s) that provided skilled interventions.In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:patient comments regarding pain, function, completion of self management/home exercise program (HEP), etc;significant improvement or adverse reaction to treatment;significant, unusual or unexpected changes in clinical status;parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;description of the skilled components of the specific exercises, training, or activities;instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);communication with patient, family, caregiver;equipment providedany additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.If grid or checklist forms are used for daily notes or exercise/activity logs, include the signature and credentials of the qualified professional/auxiliary personnel providing the service each day. Listing of exercise names (e.g., pulleys, UBE, TKE, SLR) does not alone imply that skilled treatment has been provided, especially if the exercises have been performed over multiple sessions. Be sure to occasionally document the skilled components of the exercises so they do not appear repetitive and therefore, unskilled. Documenting functional activities performed (e.g., ambulated 35 feet with min assist, upper body dressing with set up and supervision) also does not alone imply that skilled treatment was provided. The skilled components/techniques of the qualified professional/auxiliary personnel used to improve the functional activity should be occasionally documented to support medical necessity.When documenting treatment time, consistently use the CMS language of total Timed Code Treatment Minutes and Total Treatment Time. Do not use other language or abbreviations when referring to treatment minutes as it may be difficult for medical review to determine the type of minutes documented. The amount of time for each specific intervention/modality provided may also be recorded voluntarily.Do not record treatment time as Time in / Time out for the entire session as this does not accurately reflect the actual treatment time. Do not round all treatments to 15-minute increments, but rather record the actual treatment time. Also do not record as units of treatment, instead of minutes.Only intra-service care of skilled therapy services should be reflected in the time documentation. Do not include unbillable time, such as time for:changing;waiting for treatment to begin;waiting for equipment;resting;toileting; orperforming unskilled or independent exercises or activities.Discharge NotesA discharge note is required for each episode of treatment and must be written by the clinician. The discharge note is a progress report covering the time from the last progress report up to the date of discharge, and includes all required components of a progress report. The discharge note may be considered the last opportunity to justify the medical necessity of the entire treatment episode. Therefore, if a discharge summary has been completed, it may be prudent to submit it with any request of records for medical review, even if the claim under review is for a treatment period prior to the date of discharge.In the case of an unanticipated discharge, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified auxiliary 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 auxiliary 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. There must be indication that the clinician has reviewed the treatment notes and agrees to the discharge.Certifications and RecertificationsMedicare beneficiaries receiving outpatient therapy services must be under the care of a physician/NPP. Orders (sometimes called referrals) and certifications are common means of demonstrating such evidence of physician involvement.Certification, which is a coverage condition for therapy payment, requires a dated physician/NPP signature on the therapy plan of care or some other document that indicates approval of the plan of care. A certification often differs from an order or referral in that it must contain all required elements of a plan of care. To assist medical review in determining that the certification requirements are met, certifications/recertifications should include the following elements(CMS required elements are italicized):The date from which the plan of care being sent for certification becomes effective (for initial certifications, the initial evaluation date will be assumed to be the start date of the certified plan of care);Diagnoses;Long term treatment goals;Type, amount, duration and frequency of therapy services;Signature, date and professional identity of the therapist who established the plan; andDated physician/NPP signature indicating that the therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan. (Note: The CORF benefit does not recognize an NPP for certification.)Effective January 1, 2008, the interval length shall be determined by the patients needs, not to exceed 90 days. Certifications which include all the required plan of care elements will be considered valid for the longest duration in the plan (such as 3x/wk for 6 weeks which will be considered as a total of 18 treatments). If treatment continues past the longest duration specified, a recertification will be required.Documentation Requirements for Unlisted Procedure CodesUnlisted modality- In addition to a detailed service description, information in the medical record submitted to the contractor must specify the type of modality utilized and, if the modality requires the constant attendance of the qualified professional/auxilliary personnel, the time spent by the qualified professional/auxilliary personnel, one-on-one with the beneficiary.Unlisted therapeutic procedure- Information in the medical record and on the claim submitted to the contractor must specify the procedure furnished and also meet the other requirements for therapeutic procedures, i.e., the process of effecting change, through the application of clinical skills or services that attempt to improve function.Unlisted physical medicine/rehabilitation service or procedure- Information in the medical record submitted to the contractor must specify the service or procedure furnished, provide an adequate description of the nature, extent, and need for the procedure, and the time, effort, and equipment necessary to provide the service.Unlisted procedure, casting or strapping- Information in the medical record submitted to the contractor must specify the service. It should also indicate the nature of the injury being treated and the anticipated outcome of the treatment.