(Medicare Benefit Policy Manual)

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   o If complicating factors (complexities) affect treatment, describe why or how.  For example:  Cardiac dysrhythmia is not a condition for which a therapist would directly treat a patient, but in some patients such dysrhythmias may so directly and significant ly affect the pace of progress in treatment for other conditions as to require an exception to caps for necessary services.  Documentation should indicate how the progress was affected by the complexity.  Or, the severity of the patients condition as reported on a functional measurement tool may be so great as to suggest extended treatment is anticipated; and/or   o Generalized or multiple conditions.  The beneficiary has, in addition to the primary condition being treated, another disease or condition being treated, or generalized musculoskeletal conditions, or conditions affecting multiple sites and these conditions  will directly and significantly impact the rate of recovery; and/or.   o Mental or cognitive disorder.  The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will directly and significantly impact the rate of recovery; and/or.   o Identification of factors that impact severity including e.g., age, time since onset, cause of the condition, stability of symptoms, how typical/atypical are the symptoms of the diagnosed condition, availability of an intervention/treatment known to be eff ective, predictability of progress.  Documentation supporting medical care prior to the current episode, if any, (or document none) including, e.g.,  o Record of discharge from a Part A qualifying inpatient, SNF, or home health episode within 30 days of the onset of this outpatient therapy episode, or   o Identification of whether beneficiary was treated for this same condition previously by the same therapy discipline (regardless of where prior services were furnished; and   o Record of a previous episode of therapy treatment from the same or different therapy discipline in the past year.   Documentation required to indicate beneficiary health related to quality of life, specifically,   o The beneficiarys response to the following question of self -related health:  At the present time, would you say that your health is excellent, very good, fair, or poor?  If the beneficiary is unable to respond, indicate why; and  Documentation required to indicate beneficiary social support including, specifically,   o Where does the beneficiary live (or intend to live) at the conclusion of this outpatient therapy episode? (e.g., private home, private apartment, rented room, group home, board and care apartment, assisted living, SNF), and   o Who does beneficiary live with (or intend to live with) at the conclusion of this outpatient therapy episode? (e.g., lives alone, spouse/significant other, child/children, other relative, unrelated person(s), personal care attendant), and   o Does the beneficiary require this outpatient therapy plan of care in order to return to a premorbid (or reside in a new) living environment, and  o Does the beneficiary require this outpatient therapy plan of care in order to reduce Activities of Daily Living (ADL) or Instrumental Activities of Daily Living or (IADL) assistance to a premorbid level or to reside in a new level of living environment (document prior level of independence and current assistance needs); and   *Documentation required to indicate objective, measurable beneficiary physical function including, e.g.,  o Functional assessment individual item and summary scores (and comparisons to prior assessment scores) from commercially available therapy outcomes instruments other than those listed above; or   o Functional assessment scores (and comparisons to prior assessment scores) from tests and measurements validated in the professional literature that are appropriate for the condition/function being measured; or   o Other measurable progress towards identified goals for functioning in the home environment at the conclusion of this therapy episode of care.    Clinicians clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools; and   A determination that treatment is not needed, or, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.   NOTE :  When the Evaluation Serves as the Plan of Care.  When an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP.  The goal, frequency, and duration of treatment are implied in the diagnosis and one- time service.  The referral/order of a physician/ NPP is the certification that the evaluation is needed and the patient is under the care of a physician.  Therefore, when evaluation is the only service, a referral/order and evaluation are the only required documentation.  If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation.  A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient.  The time spent in evaluation shall not also be billed as treatment time.  Evaluation minutes are untimed and are part of the total treatment minutes, but minutes of evaluation shall not be included in the minutes for timed codes reported in the treatment notes.   Re-evaluations shall be included in the documentation sent to contractors when a re-evaluation has been performed.  See the definition in section 220.  Re- evaluations are usually focused on the current treatment and might not be as extensive as initial evaluations.  Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation.  A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services.  A formal re -evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation.  Indications for a re-evaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care.   A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.   A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services.  Reevaluation requires the same professional skills as evaluation.  The minutes for re-evaluation are documented in the same manner as the minutes for evaluation.  Current Procedural Terminology does not define a re- evaluation code for speech -language pathology; use the evaluation code.  Plan of Care.  See section 220.1.2 for requirements of the plan.  The evaluation and plan may be reported in two separate documents or a single combined document.  D.  Progress Report   The progress report provides justification for the medical necessity of treatment.   Contractors shall determine the necessity of services based on the delivery of services as directed in the plan and as documented in the treatment notes and progress report.  For Medicare payment purposes, information required in progress reports shall be written by a clinician that is, either the physician/NPP who provides or supervises the services, or by the therapist who provides the services and supervises an assistant.  It is not required that the referring or supervising physician/NPP sign the progress reports written by a PT, OT or SLP.   Timing.   The minimum progress report period shall be at least once every 10 treatment days.  The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, re-evaluation or treatment.  Regardless of the date on which the report is actually written (and dated), the end of the progress report period is either a date chosen by the clinician or the 10th treatment day, whichever is shorter.  The next treatment day  begins the next reporting period.  The progress report period requirements are complete when both the elements of the progress report and the clinicians active participation in treatment have been documented.  For example, for a patient evaluated on Monday, October 1 and being treated five times a week, on weekdays:  On October 5, (before it is required), the clinician may choose to write a progress report for the last weeks treatment (from October 1 to October  5).  October 5 ends the reporting period and the next treatment on Monday, October 8 begins the next reporting period.  If the clinician does not choose to write a report for the next week, the next report is required to cover October 8 through October 19, which would be 10 treatment days.  It should be emphasized that the dates for recertification of plans of care do not affect the dates for required progress reports.  (Consideration of the case in preparation for a report may lead the therapist to request early recertification.  However, each report does not require recertification of the plan, and there may be several reports between recertifications).  In many settings, weekly progress reports are voluntarily prepared to review progress, describe the skilled treatment, update goals, and inform physician/NPPs or other staff.  The clinical judgment demonstrated in frequent reports may help justify that the skills of a therapist are being applied, and that services are medically necessary.   Absences .  Holidays, sick days or other patient absences may fall within the progress report period.  Days on which a patient does not encounter qualified professional or qualified personnel for treatment, evaluation or re-evaluation do not count as treatment days.  However, absences do not affect the requirement for a progress report at least once during each progress report period.  If the patient is absent unexpectedly at the end of the reporting period, when the clinician has not yet provided the requir ed active participation during that reporting period, a progress report is still required, but without the clinicians active participation in treatment, the requirements of the progress report period are incomplete.   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.