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This audit template is a tool for managers and clinicians to assess compliance with Medicare requirements for outpatient speech-language pathology services. It is meant to be an internal mechanism for SLP practices and programs to determine whether documentation, coding, and billing practices will withstand scrutiny, and to provide an educational resource to improve the organization's clinical and business processes.
Individual Record Worksheet
Patient Name: ____________________ MRN:____________________ Acct.__________
Referring Physician: _______________DOS:____________ Today’s Date: ___________
Qualified Therapy Staff:
Speech-language pathology services are offered only by qualified providers.
Yes_____ No_____
The services provided are of such a level of complexity and sophistication that such services can be provided safely and effectively only by or under the supervision of a speech-language pathologist.
Yes_____ No_____
Physician/Non-Physician Practitioner (i.e., nurse practitioner, physician assistant or clinical nurse specialist) Certification/Approval of Therapy Services:
Individuals receiving outpatient therapy services must be under the care of a physician/NPP. The physician/NPP must certify approval of the plan of care/treatment. Certification for services should be obtained as soon as possible after the plan of care is established (before the end of the first 30-day interval of treatment). Certification may be documented by signature or verbal order, and dated before the end of the first care interval. If the order to certify is verbal, it must be followed within 14 days by a signature to be a timely certification.
All records for Medicare beneficiaries contain the required certification of the plan of care.
Yes_____ No_____
If applicable, the physician/NPP who is responsible for the patient’s care at that time recertifies the plan of treatment every 30 days.
Yes_____ No_____
Evaluation:
The initial evaluation or plan of care including an evaluation, documents the necessity for a course of therapy through objective findings and subjective patient self-reporting.
The evaluation includes: a diagnosis and description of the specific problem to be evaluated and/or treated. All conditions and complexities that may impact treatment are described. Description may include premorbid function, date of onset, current function.
Yes_____ No_____
Objective measurements (preferably standardized patient assessment instruments and/or outcomes measurement tools related to current functional status), when available and appropriate, are documented.
Yes_____ No_____
The clinician’s clinical judgments or subjective impressions describe the patient’s current functional status of the condition being evaluated, when these statements provide further information to supplement measurement tools.
Yes_____ No_____
Prognosis is given for return to premorbid function or maximum expected condition with expected time frame and a plan of care.
Yes_____ No_____
Plan of Care
The plan of care must relate directly and specifically to a written treatment plan. The plan must be established before treatment is begun. The plan is established when it is developed (written or dictated). The plan may be established by a physician/NPP and/or the SLP who will provide the services. The evaluation and treatment may occur (and are both billable) on the same day or at subsequent visits. It is appropriate that treatment begins when the plan is established. Therapy may begin based on a dictated plan after it has been committed to writing and before it is signed (provided it is signed by close-of-business on the day following dictation by the person who established the plan). Treatment may begin before the plan is committed to writing only if the treatment is performed by the same qualified professional who established the plan and the plan is established and signed by close-of-business on the next day by the same qualified professional.
The plan of care was established, written, and signed in accordance with Medicare requirements.
Yes_____ No_____
The plan of care, at a minimum, contains the following information: therapy diagnoses and underlying medical diagnoses; long-term treatment goals; and type, amount, and frequency of therapy services.
Yes_____ No_____
Changes to the plan of care are made in writing in the patient’s record and signed by one of the professionals responsible for the patient’s care (physician/NPP, SLP, or the RN or physician/NPP on the staff of the facility pursuant to verbal orders of the physician/NPP or therapist).
Yes_____ No_____
Progress reports:
The progress report provides justification for the medical necessity of treatment. Information required in progress reports should be provided at least once every 10 treatment days or once during the 30-day/one-month interval, whichever is less. The evaluation and plan of care are incorporated into the progress report and it is not necessary to repeat information about those documents in the progress report.
Progress reports are documented at the required 30-day intervals, including date of the beginning of the interval and date the report was written (which must occur during the interval), and signature (or electronic identification) of professional completing the report.
Yes_____ No_____
The report includes objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment. Descriptions make identifiable reference to the goals in the current plan of care. The 30-day interval report adds, changes, or deletes short-term goals, or deletes completed long-term goals.
Yes_____ No_____
Documentation includes an assessment of improvement and progress made (or lack thereof) for this reporting period; techniques used to achieve goals; the patient’s continued potential to make "significant, practical improvement," and changes in the plan of treatment.
Yes_____ No_____
Plans for continuing treatment, reference to additional evaluation results, and treatment plan revisions, as applicable, are documented.
Yes_____ No_____
The Discharge Note is a interval note covering the period from the last interval note to the date of discharge. This note may summarize the entire episode of treatment, or justify services that have extended beyond those usually expected for the patient's condition. The discharge note is the last opportunity to justify medical necessity for the entire treatment episode.
The discharge note provides suitable information for review and justification of services.
Yes_____ No_____
Treatment Encounter Note:
The treatment encounter note documents every treatment day and every therapy service. The note must record the elements listed below. In addition, the encounter note may include the following optional elements: patient self-report; adverse reaction to intervention; communication/consultation with other providers; significant or unusual changes in clinical status; equipment provided; and/or any additional relevant information the qualified professional wishes to provide.
Date of treatment is documented :
Yes_____ No_____
Total timed code treatment minutes and total treatment time (timed and untimed codes) is provided.
Yes_____ No_____
Each specific intervention provided and billed, for both timed and untimed codes.
Yes_____ No_____
Signature and professional identification of the qualified professional who provided the service and list of each person who contributed to treatment during the encounter (e.g., assistants or students).
Yes_____ No_____
Group Therapy:
Speech-language group therapy sessions are covered by Medicare if they are rendered under an individualized plan of care; have no more than four (4) group members; and group therapy does not represent the entire plan of treatment. Group sessions must be conducted by a qualified SLP.
Group therapy services meet Medicare requirements.
Yes_____ No_____
Note: In a hospital setting, group therapy codes may be billed more than once per day, but sufficient documentation must be provided to determine medical necessity and clinical appropriateness.
Source Documents:
Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, Sections 220 and 230. Accessed at: www.cms.hhs.gov
Medicare Claims Processing Manual, Chapter 5, Section 20.2, Reporting of Service Units – Form CMS-1500 and Form CMS-1450. Accessed at www.cms.hhs.gov
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