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Documentation continues to play a critical role in evaluating the need for Medicare outpatient therapy services and is usually reviewed by Medicare contract nurses rather than SLPs. In maintaining and submitting documentation, an SLP should not assume that the reviewer will understand why the service requires the skill of an SLP and should include additional information.
CMS states that objective evidence consists of standardized patient assessment instruments, outcomes measurement tools or measurable assessments of functional outcomes. The agency also states that the use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justification for continued treatment. While such tools are not required, CMS does state that they will enhance the justification for the need of therapy.
ASHA's National Outcomes Measurement System (NOMS) was used by CMS to help determine the range of speech-language pathology diagnoses for the Medicare therapy cap exceptions process. SLPs are encouraged to participate in outcomes reporting and benchmarking by becoming a NOMS-certified user.
When in doubt, contact the Medicare contractor and request that they provide educational models or in-service staff training on documentation. You should consider coordinating this with your state association to make the invitation more attractive to the contractor and provide access to more of your colleagues.
CMS has outlined its minimal documentation requirements in its Benefit Policy Manual. SLPs should monitor their Medicare contractor's Web site for additional updates as there may be changes made to the local coverage determinations as a result of CMS instructions. All therapy notes must be signed by the qualified professional and include credentials. When a student is assisting, the student may write the documentation, but the signature of the SLP is required.
Required Documentation
When submitting documentation to the contractor, provide the following information unless otherwise specified by the contractor:
Evaluation and Certified Plan of Care, including initial evaluation and reevaluation relevant to the episode being reviewed. It should include:
- a diagnosis and description of the specific problem being evaluated and or treated
- objective measures, preferably a standardized patient assessment instrument or outcomes measurement tool related to current functional status
- clinician's clinical judgment or subjective impressions of the patient's condition
- determination of the need for treatment
Certification
- assurance that the patient is under the care of a physician
Progress Reports (when treatment exceeds 10 treatment days or 30 calendar treatment days/one month, whichever is less). The clinician must complete a progress report at least once during each interval of treatment. The progress report should include:
- date of the beginning of the treatment interval
- date the report was written
- signature of the qualified professional
- objective reports of the patient's progress
- objective measurements of changes in status relative to current goals
- plans for continuing treatment
- changes to long- and short-term treatment goals
Treatment Encounter Notes
These may also serve as progress reports when required information is included in the notes. The purpose of the encounter note is not to document medical necessity, but to create a record of all encounters and skilled intervention. Tips to keep in mind with encounter notes are as follows:
- Documentation is required for every treatment day, and every therapy service.
- The encounter note must record the name of the treatment, intervention or activity provided.
- Total treatment time must be documented.
- The signature of the professional delivering the service must be included.
If a treatment is added or changed between the progress note intervals, the change must be recorded and justified in the medical record. Frequent professional judgments resulting in upgrades to the patient's activity show skilled treatment. Objective measurements showing improvement are very helpful.
If there is no improvement, explain the setbacks, illness, new conditions, or social circumstances that are impeding progress and why it is believed that progress is still attainable. Activities that are repetitive or routine, or easy enough to explain to an aide or caretaker could be questioned by the reviewer.
Exception to Therapy Caps
The records must justify services over the cap. A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands their reasoning for the use of the KX modifier.
ASHA has other information that could assist in your documentation efforts. For additional information, contact ASHA's Health Care Economic and Advocacy Team at reimbursement@asha.org.
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