Functional outcome reporting and manual medical review are
initiatives that have added complexity and sometimes confusion about
documenting services to Medicare beneficiaries. And the Medicare policy manual
makes the need for compliance abundantly clear: Medicare will reimburse for
outpatient therapy services—or Part B therapy services provided in skilled
nursing facilities—only when the patient's medical record and the information on the claim form consistently and accurately report covered services.
But Medicare terminology often makes it difficult for SLPs
to understand the rules for documentation and reporting, much less follow them
and demonstrate the skilled services they provide. These definitions,
summarized from the "Medicare Benefit Policy Manual [PDF]" (Chapter 15, Section 220.3), may help:
Evaluation is a comprehensive service that requires
professional skills. It is based on objective measurements and subjective
evaluations of a patient's performance and functional abilities. Evaluation is warranted, for example, for a new diagnosis or if a condition is treated in a new setting. Evaluation has an associated reimbursable billing code.
Sometimes, an evaluation is the only service an SLP provides
to a Medicare beneficiary. In this case, the evaluation serves as the plan of care
(see below) if it contains a diagnosis or a description of the condition that
the referring physician or nonphysician practitioner can use to make a
diagnosis. Therefore, when evaluation is the only service, the physician's referral and the SLP's evaluation are the only documentation Medicare requires for reimbursement and for functional outcome reporting.
A re-evaluation is billable as an evaluation when an
assessment indicates a significant change in patient condition that was not
anticipated in the plan of care.
Assessment has a specific meaning different from evaluation
in Medicare terminology. Assessment has no separate billing code; it is part of
the skilled services delivered by a clinician during a treatment session.
Assessment uses clinical observation, patient self-report and objective data to
make clinical judgments about progress toward goals or to determine the need
for a formal evaluation.
Plan of care is the written treatment plan, which includes
diagnoses; long-term treatment goals; and type, amount, duration and frequency
of therapy services. The plan must be established before treatment begins and
consistent with the related evaluation, which may be attached to the plan and
is considered part of it. A patient receiving services from more than one
discipline—occupational or physical therapy, for example—must have a separate
plan for each therapy discipline.
Certification/recertification is the approval from the
physician or nonphysician practitioner for the plan of care. The SLP must receive
this approval within 30 days of initial treatment. Certification requires a
dated signature on the plan of care, or other document that indicates approval
of the plan of care. Recertification is required at least every 90 days for a
plan of care that does not change substantially. Recertification is required
within 30 days of the initial treatment if the plan of care is
modified significantly—for example, by adding a new condition, changing
long-term goals or responding to changes in the patient's condition.
Functional reporting is a new Medicare requirement in 2013
for Medicare Part B claims. All providers, including SLPs, must report
nonpayable G-codes and related modifiers to convey information about the
patient's functional status at specified points during treatment. Providers must include these codes and modifiers in the plan of care and in the progress notes. (For more information, see G-Codes and Severity Modifiers for Claims-Based Outcomes Reporting.)
Progress notes provide ongoing justification for the medical
necessity of treatment and the need for an SLP's skilled service. Medicare requires providers to record progress notes at least once every 10 treatment days. Progress notes must include assessment of improvement and/or extent of progress, plans for continuing treatment, reference to additional evaluation results, treatment plan revisions, and changes to long- or short-term goals. Progress notes also must include functional reporting, including the G-code with severity modifier and an explanation of the choice of modifier.
The discharge note—the final progress note—includes the
required elements of the progress note. If the discharge is unanticipated, the
clinician may base his or her judgments of the functional status at discharge
on the treatment notes and verbal reports of the assistant or qualified
personnel. The discharge note is the last opportunity to justify medical
necessity for the entire treatment episode.
Only skilled therapy services may be billed under Medicare.
They are defined as meeting the following two criteria:
- They must be provided by the qualified professional and
documented in the plan of care and progress notes.
- They require the expertise, knowledge, clinical judgment and
decision-making abilities of a clinician for safe and effective results. They
cannot be provided independently by assistants, qualified personnel, caretakers
or the patient.
Unskilled services are repetitive, reinforce previously
learned skills, or maintain function in a maintenance program.
Treatment day is defined as a single calendar day on which
treatment, evaluation and/or re-evaluation is provided. A single treatment day
could include multiple visits or treatment sessions/encounters.
Treatment notes are a record for each treatment day. They
create a record of skilled intervention and time of service to justify the
billing codes used on a claim. Every treatment day must be documented, and
every treatment service must include date, service provided, total time in
treatment and provider signature. There is no standard format for treatment notes.
For more information on documentation requirements for SLPs
in health care settings, visit our documentation page.