Mississippi Administrative Code › Title 23 - Division of Medicaid › Part 213 - Therapy Services › Chapter 1 - Physical Therapy › Rule 23-213-1.11 - Documentation

Current through June 25, 2024
A. Physical therapy provider records must
				document and maintain records in accordance with requirements set forth in
				Miss. Admin. Code Part 200, Rule
				1.3.
B. Required documentation by a servicing
				physical therapy provider includes, but is not limited to, the following:
1. Beneficiary demographic information,
2. A copy of the Certificate of
				Medical Necessity for Initial Referral/Orders completed by the prescribing
				provider,
3. Signed consent for
				treatment,
4. Original copies of
				all Outpatient Therapy Evaluation/Re-Evaluation specific to the therapy
				ordered,
5. The original copies of
				all Outpatient Therapy Plan of Care specific to the therapy requested,
6. The original copies of all
				tests performed or a list of all tests performed, test results, and the written
				evaluation reports,
7. Treatment
				log if treatment times are not documented in the progress notes including all
				requirements for timed codes as follows:
a)
				The Division of Medicaid defines timed codes as procedure codes that reference
				a time per unit.
b) The Division
				of Medicaid covers units of timed codes based upon the total time actually
				spent in the delivery of the service.
c) The Division of Medicaid considers the
				following activities as not part of the total treatment time:
1) Pre and post-delivery of services,
2) Time the beneficiary spends not
				being treated, and
3) Time waiting
				for equipment or for treatment to begin.
d) The Division of Medicaid defines untimed
				codes as procedure codes that are not defined by a specific time frame.
e) The Division of Medicaid does
				not require documentation of the treatment time for untimed codes.
f) The Division of Medicaid only covers one
				(1) unit for untimed codes regardless of the amount of time taken to complete
				the service.
8.
				Progress notes:
a) Must be documented at
				least weekly,
b) Must include:
1) Date/time of service,
2) Specific treatment modalities/procedures
				performed,
3) Beneficiary's
				response to treatment,
4)
				Functional progress,
5) Problems
				interfering with progress,
6)
				Education/teaching activities and results,
7) Conferences,
8) Progress toward discharge goals/home
				program activities, and
9) The
				signature and title of the therapist providing the service(s).
c) If treatment times are
				documented in the progress notes in lieu of a treatment log, all requirements
				for timed codes must be met as follows:
1)
				The Division of Medicaid defines timed codes as procedure codes that reference
				a time per unit.
2) The Division
				of Medicaid covers units of timed codes based upon the total time actually
				spent in the delivery of the service.
3) The Division of Medicaid considers the
				following activities as not part of the total treatment time:
(a) Pre and post-delivery of services. ,
(b) Time the beneficiary spends
				not being treated, and
(c) Time
				waiting for equipment or for treatment to begin.
4) The Division of Medicaid defines untimed
				codes as procedure codes that are not defined by a specific time frame.
5) The Division of Medicaid does
				not require documentation of the treatment time for untimed codes.
6) The Division of Medicaid only covers one
				(1) unit for untimed codes regardless of the amount of time taken to complete
				the service.
9. Discharge summary, if applicable, and
10. A copy of the completed prior
				approval authorization form with prior approval, if applicable.