(Medicare Benefit Policy Manual)

 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    Total timed code treatment minutes  and total treatment time in minutes .  Total treatment time includes the minutes for timed code treatment and untimed code treatment.  Total treatment time does not include time for services that are not billable (e.g., rest periods).  For Medicare purposes, it is not required that unbilled services that are not part of the total treatment minutes be recorded, although they may be included voluntarily to provide an accurate description of the treatment, show consistency with the plan, or comply with state or local policies.  The amount of time for each specific intervention/modality provided to the patient may also be recorded voluntarily, but contractors shall not require it, as it is indicated in the billing.  The billing and the total timed code treatment minutes must be consistent.  See Pub. 100-04, chapter 5, section 20.2 for description of billing timed codes; and   Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment (i.e., the signature of Kathleen Smith, PTA, with notation of phone consultation with Judy Jones, PT, supervisor, when permitted by state and local law).  The signature and identification of the supervisor need not be on each treatment note, unless the supervisor actively participated in the treatment.  Since a clinician must be identified on the plan of care and the progress report, the name and professional identification of the supervisor responsible for the treatment is assumed to be the clinician who wrote the plan or report.  When the treatment is supervised without active participation by the supervisor, the supervisor is not required to cosign the treatment note written by a qualified professional.  When the responsible supervisor is absent, the presence of a similarly qualified supervisor on the clinic roster for that day is sufficient documentation and it is not required that the substitute supervisor sign or be identified in the documentation.  If a treatment is added or changed under the direction of a clinician during the treatment days between the progress reports, the change must be recorded and justified on the medical record, either in the treatment note or the progress report, as determined by the policies of the provider/supplier.  New exercises added or changes made to the exercise program help justify that the services are skilled.  For example:  The original plan was for therapeutic activities, gait training and neuromuscular re- educati on.  On Feb. 1 clinician added electrical stim. to address shoulder pain.  Documentation of each treatment may also include the following optional elements to be mentioned only if the qualified professional recording the note determines they are appropriate and relevant.  If these are not recorded daily, any relevant information should be included in the progress report.   Patient self -report;    Adverse reaction to intervention;   Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist, etc.);   Significant, unusual or unexpected changes in clinical status;    Equipment provided; and/or    Any additional relevant information the qualified professional finds appropriate.   See Pub. 100- 04, Medicare Claims Processing Manual, chapter 5, section 20.2 for instructions on how to count minutes.  It is important that the total number of timed treatment minutes support the billing of units on the claim, and that the total treatment time reflects services billed as untimed codes.   220.4  Functional Reporting  (Rev. 255, Issued: 01- 25-19, Effective: 01 - 01- 19, Implementation: 02- 26-19)  NOTE : In the calendar year (CY) 2019 Physician Fee Schedule (PFS) final rule, CMS -1693-F, after consideration of stakeholder comments for burden reduction, a review of all of the requirements under section 3005(g) of Middle Class Tax Relief and Jobs Creation Act  of 2012 (MCTRJCA), and in light of the statutory amendments to section 1833(g) of the Act, via section 50202 of Bipartisan Budget Act of 2018 to repeal the therapy caps, CMS concluded that continued collection of functional reporting data through the same or reduced format would not yield additional information to inform future analyses or to serve as a basis for reforms to the payment system for therapy services.  To reduce the burden of reporting for providers of therapy services, the CY 2019 PFS f inal rule ended the requirements of reporting the functional limitation nonpayable HCPCS G -codes and severity modifiers on claims for therapy services and the associated documentation requirements in medical records, effective for dates of service on and a fter January 1, 2019.  The rule also revised regulation text at 42 CFR 410.59, 410.60, 410.61, 410.62, 410.105, accordingly.    The instructions below apply only to dates of service when the functional reporting requirements were effective, January 1, 2013 through December 31, 2018.   A.  Selecting the G -codes to Use in Functional Reporting.   There are 42 functional G -codes, 14 sets of three codes each, for that can be used in identifying the functional limitation being reported.   Six of the G -code sets are generally for PT and OT functional limitations and eight sets of G -codes are for SLP fu nctional limitations. (For a list of these codes and descriptors, see Pub. 100- 04, Medicare Claims Processing Manual, chapter 5, section 10.6 F.)   Only one functional limitation shall be reported at a time.  Consequently, the clinician must select the G -code set for the functional limitation that most closely relates to the primary functional limitation being treated or the one that is the primary re ason for treatment. When the beneficiary has more than one functional limitation, the clinician may need to make a determination as to which functional limitation is primary.  In these cases, the clinician may choose the functional limitation that is:    Most clinically relevant to a successful outcome for the beneficiary;    The one that would yield the quickest and/or greatest functional progress; or    The one that is the greatest priority for the beneficiary. In all cases, this primary functional limitation should reflect the predominant limitation that the furnished therapy services are intended to address.   For services typically reported as PT or OT, the clinician reports one of the Other PT/OT functional G -codes sets to report when one of the four PT/OT categorical code sets does not describe the beneficiarys functional limitation, as follows:    a beneficiarys functional limitation that is not defined by one of the four categories;    a beneficiary whose therapy services are not intended to treat a functional limitation; or    a beneficiarys functional limitation where an overall, composite, or other score from a functional assessment tool is used and does not clearly represent a functional limitation defined by one of the above four categorical PT/OT code sets.   In addition, the subsequent Other PT/OT G -code set is only reported after the primary Other PT/OT G -code set has been reported for the beneficiary during the same episode of care.   For services typically reported as SLP services, the clinician uses the Other SLP functional G -code to report when the functional limitation being treated is not represented by one of the seven categorical SLP functional measures.  In addition, the Othe r SLP G-code set is used to report where an overall, composite, or other score from an assessment tool that does not clearly represent a functional limitation defined by one of the seven categorical SLP measures.   B.  Selecting the severity modifiers to use in functional reporting/documenting.   Each G -code requires one of the following severity modifiers.  When the clinician reports any of the following a modifier is used to convey the severity of the functional limitation: current status, the goal status and the discharge status.  Modifier  Impairment Limitation Restriction  CH 0 percent impaired, limited or restricted  CI At least 1 percent but less than 20 percent impaired, limited or restricted  CJ At least 20 percent but less than 40 percent impaired, limited or restricted  CK At least 40 percent but less than 60 percent impaired, limited or restricted  Modifier  Impairment Limitation Restriction  CL At least 60 percent but less than 80 percent impaired, limited or restricted  CM At least 80 percent but less than 100 percent impaired, limited or restricted  CN 100 percent impaired, limited or restricted   The severity modifier reflects the beneficiarys percentage of functional impairment as determined by the clinician furnishing the therapy services for each functional status:  current, goal, or discharge. In selecting the severity modifier, the clinician:    Uses the severity modifier that reflects the score from a functional assessment tool or other performance measurement instrument, as appropriate.    Uses his/her clinical judgment to combine the results of multiple measurement tools used during the evaluative process to inform clinical decision making to determine a functional limitation percentage.    Uses his/her clinical judgment in the assignment of the appropriate modifier.   Uses the CH modifier to reflect a zero percent impairment when the therapy services being furnished are not intended to treat (or address) a functional limitation.   In some cases the modifier will be the same for current status and goal status. For example:  where improvement is expected but it is not expected to be enough to move to another modifier, such as from 10 percent to 15 percent, the same severity modifier would be used in reporting the current and goal status. Also, when the clinician does not expect improvement, such as for individuals receiving maintenance therapy, the modifier used for projected goal status will be the same as the one for current status. In these cases, the discharge status may also include the same modifier.   Therapists must document in the medical record how they made the modifier selection so that the same process can be followed at succeeding assessment intervals.   C.  Documentation of G -code and Severity Modifier Selection.   Documentation of the nonpayable G -codes and severity modifiers regarding functional limitations reported on claims must be included in the patients medical record of therapy services for each required reporting. (See Pub. 100- 04, Medicare Claims Processin g Manual, chapter 5, section 10.6 for details about the functional reporting requirements on claims for therapy services, including PT, OT, and SLP services furnished in CORFs.)   Documentation of functional reporting in the medical record of therapy services must be completed by the clinician furnishing the therapy services:    The qualified therapist furnishing the therapy services    The physician/NPP personally furnishing the therapy services    The qualified therapist furnishing services incident to the physician/NPP    The physician/NPP for incident to services furnished by qualified personnel, who are not qualified therapists.   The qualified therapist furnishing the PT, OT, or SLP services in a CORF.   230 - Practice of Physical Therapy, Occupational Therapy, and Speech -Language Pathology  (Rev. 63, Issued: 12- 29-06, Effective: 01 -01-07, Implementation: on or before 01- 29-07)  A.  Group Therapy Services.   Contractors pay for outpatient physical therapy services (which includes outpatient speech- language pathology services) and outpatient occupational therapy services provided simultaneously to two or more individuals by a practitioner as group therapy ser vices (97150).  The individuals can be, but need not be performing the same activity.  The physician or therapist involved in group therapy services must be in constant attendance, but one -on-one patient contact is not required.   B.  Therapy Students   1.  General   Only the services of the therapist can be billed and paid under Medicare Part B.  The services performed by a student are not reimbursed even if provided under line of sight supervision of the therapist; however, the presence of the student in the room  does not make the service unbillable.  Pay for the direct (one -to-one) patient contact services of the physician or therapist provided to Medicare Part B patients.  Group therapy services performed by a therapist or physician may be billed when a student is also present in the room.  EXAMPLES:   Therapists may bill and be paid for the provision of services in the following scenarios:    The qualified practitioner is present and in the room for the entire session.  The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.    The qualified practitioner is present in the room guiding the student in service delivery when the therapy student and the therapy assistant student are participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.    The qualified practitioner is responsible for the services and as such, signs all documentation.  (A student may, of course, also sign but it is not necessary since the Part B payment is for the clinicians service, not for the students services).   2.  Therapy Assistants as Clinical Instructors   Physical therapist assistants and occupational therapy assistants are not precluded from serving as clinical instructors for therapy students, while providing services within their scope of work and performed under the direction and supervision of a licens ed physical or occupational therapist to a Medicare beneficiary.