Overview of Documentation for Medicare Outpatient Therapy Services

Documentation will continue to play a critical role in explaining the need for Medicare therapy services and justification on the use of the exceptions process. Remember that documentation is usually reviewed by Medicare contract nurses, rather than speech-language pathologists. 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 that may be needed by the reviewer.

When in doubt, contact the Medicare contractor and request that they provide education models or in-service staff training on documentation. You should consider coordinating this with your state speech-language-hearing association to make the invitation more attractive to the contractor and provide access to more of your colleagues.

The Centers for Medicare and Medicaid Services (CMS) states that therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services. Documentation should also include objective measures of the patient's improvement as a means to justify therapy services above the targeted medical review threshold. It is imperative that SLPs ensure that documentation is legible, relevant, and sufficient to justify the services billed.

Documentation must comply with all legal/regulatory requirements applicable to Medicare claims. CMS outlines its minimal documentation requirement in the Medicare Benefit Policy Manual Publication, 100-02, Chapter 15, Section 220.3 [PDF]. A task force of local Medicare Administrative Contractors (MACs) also developed a guide to educate providers on common documentation errors for outpatient rehabilitation therapy services. Although the requirements are summarized below, SLPs should become familiar with all the requirements as listed in the CMS publication.

Summary

In general, Medicare requires that therapy services are of appropriate type, frequency, intensity, and duration for the individual needs of the patient. Documentation should:

• Establish the variables that influence the patient's condition, especially those factors that influence the clinician's decision to provide more services than are typical for the individual's condition.
• Establish through objective measurements that the patient is making progress toward goals. CMS realizes that regression and plateaus can happen during treatment, and recommends that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.

The following types of documentation of therapy services are expected to be submitted in response to any contractor request for documentation, unless otherwise specified. The timelines are minimum requirements for Medicare payment.

Evaluation

The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings. Documentation of the evaluation should list the conditions and complexities and, where it is not obvious, describe the impact of the conditions and complexities on the prognosis and/or the plan for treatment so that it is clear to a reviewer that the services planned are appropriate for the individual.

Evaluation shall include:

• A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. The diagnosis should be specific and as relevant to the problem to be treated as possible. The treatment diagnosis may or may not be identified by the therapist, depending on their scope of practice. Where a diagnosis is not allowed, CMS advises the use of a condition description similar to the appropriate ICD-9 code.
• Results of ASHA's national outcomes measurement system (optional). Additional information can be found on the NOMS section of the ASHA website.
• If NOMS is not used, the record shall contain documentation to indicate objective, measurable beneficiary physical function including, e.g.,
1. 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
2. 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
3. Other measurable progress towards identified goals for functioning in the home environment at the conclusion of this therapy episode of care.

When an evaluation is the only service provided in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/nonphysician practitioner (NPP). The goal, frequency, intensity 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.

Plan of Care/Certification of the Plan of Care

The plan of care shall be consistent with the related evaluation. The evaluation and plan may be reported in two separate documents or a single combined document. The certified plan of care ensures that the patient is under the care of a physician or NPP.

Long term treatment goals should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care. The plan of care shall contain, at minimum, the following information:

• Diagnoses;
• Long term treatment goals; and
• Type, amount, duration, and frequency of therapy services.

The amount of treatment refers to the number of times in a day the type of treatment will be provided. The frequency refers to the number of times in a week the type of treatment is provided. The duration is the number of weeks, or the number of treatment sessions.

Progress Reports

The progress report provides justification for the medical necessity of treatment. A clinician must complete a progress report at least once every 10 treatment days or at least once during each certification interval, whichever is less. The beginning of 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.

Progress notes should contain:

• An assessment of improvement, extent of progress (or lack thereof) toward each goal;
• Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician's progress report; and
• Changes to long or short term goals, discharge, or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.

Documentation should justify the necessity of the services provided during the reporting period, and include, for example, objective evidence or a clinically supportable statement of expectation that the patient's condition has the potential to improve or is improving in response to therapy; maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

Objective evidence consists of standardized patient assessment instruments, outcome measurements tools, or measurable assessments of functional outcome such as NOMS. Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment. Such tools are not required, but their use will enhance the justification for needed therapy.

CMS Example of a SLP Progress Note:

The Plan states diagnosis is dysphagia secondary to other late effects of CVA. Patient is on a restricted diet and wants to drink thick liquids.

Therapy is planned 3X week, 45 minute sessions for 6 weeks.

Long term goal is to consume a mechanical soft diet with thin liquids without complications such as aspiration pneumonia.

Short Term

1. Goal 1: Patient will improve rate of laryngeal elevation/timing of closure by using the super-supraglottic swallow on saliva swallows without cues on 90% of trials.
2. Goal 2: Patient will compensate for reduced laryngeal elevation by controlling bolus size to ½ teaspoon without cues 100%.

The Progress Report for 1/3/06 to 1/29/06 states:

1. Improved to 80% of trials;
2. Achieved. Comments: Highly motivated; spouse assists with practicing, compliant with current restrictions.

New Goal: "5. Patient will implement above strategies to swallow a sip of water without coughing for 5 consecutive trials.

Mary Johns, CCC-SLP, 1/29/06."

Note the provider is billing 92526 three times a week, consistent with the plan; progress is documented; skilled treatment is documented.

Treatment Notes

The purpose of the treatment note is not to document medical necessity, but to create a record of all encounters and skilled intervention. Documentation is required for every treatment day, every therapy service, and must include the following information:

• the encounter note must record the name of the treatment, intervention of activity provided;
• total treatment time; and
• signature of the professional furnishing the services.

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 measurement showing improvement is also helpful.

If there is no improvement, the clinicians should provide information to explain the setbacks, illness, new condition, or social circumstances that are impeding progress and why it is believed that progress is still attainable.

Discharge Note

The Discharge Note is required and shall be a progress report written by a clinician and shall cover the reporting period from the last progress report to the date of discharge. The discharge note shall include all treatment provided since the last progress report and indicate that the therapist reviewed the notes and agrees to the discharge.