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  • Medicare Treatment Note FAQs

    11 Nov 2022 10:33 AM | Zachary Edgar (Administrator)

    What is a treatment note?

    A record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service.

    What is required in each note?

    The treatment note must include the following required information:

    • Date of treatment;
    • Identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;
    • Record of the total time spent in services represented by timed codes under timed code treatment minutes;
    • Record of the total treatment time in minutes, which is a sum of the timed and untimed services;
    • Signature and credentials of each individual(s) that provided skilled interventions.

    Is there additional information that can be added to the note?

    The treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:

    • Patient comments regarding pain, function, completion of self-management/home exercise program (HEP), etc;
    • Significant improvement or adverse reaction to treatment;
    • Significant, unusual or unexpected changes in clinical status;
    • Parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;
    • Description of the skilled components of the specific exercises, training, or activities;
    • Instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;
    • Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);
    • Communication with patient, family, caregiver;
    • Equipment provided
    • Any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.

    When does the note need to be completed?

    Medicare contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the progress report or treatment note refers.

    Who must sign the treatment note?

    Signature and professional identification of the qualified professional (therapist or assistant) who furnished or supervised the services and a list of each person who contributed to that treatment.

    When the treatment is supervised without active participation by the supervisor, the supervisor is not required to cosign the treatment note written by a qualified professional.

    State law may require that the supervising therapist co-sign the note with the assistant.

    See Medicare Documentation for more information.

    Reference

    Centers for Medicare and Medicaid

    Medicare Benefit Policy Manual

    Chapter 15 – Covered Medical and Other Health Services

  • Medicare Plan of Care FAQs

    26 Oct 2022 2:48 PM | Zachary Edgar (Administrator)

    See our Medicare Plan of Care Section for more information.

    Who can establish a therapy plan of care (POC)?

    Outpatient therapy services shall be furnished under a plan established by:

    •        A physician/NPP (consultation with the treating physical therapist, occupational therapist, or speech-language pathologist is recommended. Only a physician may establish a plan of care in a CORF;

    •        The physical therapist who will provide the physical therapy services;

    •        The occupational therapist who will provide the occupational therapy services; or

    •        The speech-language pathologist who will provide the speech-language pathology services.

    Who must sign the POC?

    The person who established the plan must sign and date the plan.  The physician/NPP must also certify the plan by signing and dating it.

    See Certification and Recertification for more information.

    Can treatment begin before a POC has been established?

    Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who establishes the plan. Payment for services provided before a plan is established may be denied.

    What must be included in the POC?

    The plan of care shall contain, at minimum:

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

    How do I document the diagnosis in the POC?

    The diagnosis should be specific and as relevant to the problem being treated as possible. In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.

    The ICD-10 code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason.

    When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position.

    Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.

    How should long-term goals be documented?

    Long term treatment goals should be developed for the entire episode of care in the current setting. When the episode is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified. Goals should be measurable and pertain to identified functional impairments.

    Long-term goals should:

    • Pertain to the functional impairment findings documented in the evaluation;
    • Reflect the final level the patient is expected to achieve as a result of therapy in the current setting;
    • Be realistic, and should have a positive effect on the quality of the patient’s everyday functions;
    • Be function-based and written in objective, measurable terms with a predicted date for achieving the goals.

    Does the POC need to contain short-term goals?

    Short-term goals are not required.  Therapists typically also establish short term goals, such as goals for a week or month of therapy, to help track progress toward the goal for the episode of care. If the expected episode of care is short, for example therapy is expected to be completed in 4 to 6 treatment days, the long term and short-term goals may be the same.

    What does type of treatment mean?

    The type of treatment may be PT, OT, or SLP, or, where appropriate, the type may be a description of a specific treatment or intervention. (For example, where there is a single evaluation service, but the type is not specified, the type is assumed to be consistent with the therapy discipline (PT, OT, SLP) ordered, or of the therapist who provided the evaluation.)

    When a physician/NPP establishes a plan, the plan must specify the type (PT, OT, SLP) of therapy planned.

    What if a patient is being treated by more than on kind of therapy?

    When more than one discipline is treating a patient, each must establish a diagnosis, goals, etc. independently. However, the form of the plan and the number of plans incorporated into one document are not limited as long as the required information is present and related to each discipline separately.

    For example, a physical therapist may not provide services under an occupational therapist plan of care. However, both may be treating the patient for the same condition at different times in the same day for goals consistent with their own scope of practice.

    What does amount of treatment refer to?

    The amount of treatment refers to the number of times in a day the type of treatment will be provided. Where amount is not specified, one treatment session a day is assumed.

    What does frequency refer to?

    The frequency refers to the number of times in a week the type of treatment is provided. Where frequency is not specified, one treatment is assumed. If a scheduled holiday occurs on a treatment day that is part of the plan, it is appropriate to omit that treatment day unless the clinician who is responsible for writing progress reports determines that a brief, temporary pause in the delivery of therapy services would adversely affect the patient’s condition.

    What does duration refer to?

    The duration is the number of weeks, or the number of treatment sessions. If the episode of care is anticipated to extend beyond the 90 calendar day limit for certification of a plan, it is desirable, although not required, that the clinician also estimate the duration of the entire episode of care in this setting.

    Can the amount, frequency, or duration be changed during the episode of care?

    Yes. The plan of care can be altered by the therapist during treatment.  If the therapist changes the long-term goals, then the POC must be recertified by the physician/NPP.

    References

    Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services §220.1.2

    Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067

  • Medicare PT/OT/SLP Evaluation FAQs

    12 Oct 2022 12:40 PM | Zachary Edgar (Administrator)

    See our Medicare PT/OT/SLP Evaluations Page for more information.

    Who can perform a therapy evaluation?

    Only a clinician may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care.

    A clinician means either a physician or a physical, occupational, or speech therapist.

    Can an assistant participate in an evaluation?

    A clinician may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or re-evaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.

    When does an evaluation need to be performed?

    An evaluation must be completed prior to beginning of treatment.

    Can an evaluation and treatment be performed on the same visit?

    Yes. Once the evaluation has been completed, the therapist may start treatment.

    What must be included in the evaluation?

    A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated.

    Results of one of the following four measurement instruments are recommended, but not required:

    • National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association
    • Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)
    • Activity Measure – Post Acute Care (AM-PAC)
    • OPTIMAL by Cedaron through the American Physical Therapy Association

    - Documentation supporting illness severity or complexity.

    - Documentation supporting medical care prior to the current episode.

    - Documentation required to indicate beneficiary health related to quality of life.

    - Documentation required to indicate beneficiary social support.

    - Documentation required to indicate objective, measurable beneficiary physical function.

    When is an evaluation medically necessary?

    A new patient who has not received prior therapy services.

    A patient who has returned for additional therapy after having been discharged from prior therapy services for the same or for a different condition. Time spent evaluating this returning patient should not be coded as a re-evaluation. Prior discharge may have been due to one of the following:

    • Patient no longer significantly benefited from ongoing therapy services or;
    • Patient no longer required therapy services for an extended period of time or;
    • Patient experienced a significant change in medical status that necessitated discharge.

    A patient who is currently receiving therapy services and develops a newly diagnosed unrelated condition.

    Is an evaluation different from an assessment?

    An assessment is separate from evaluation, and is included in services or procedures, (it is not separately payable). The term assessment as used in Medicare manuals related to therapy services is distinguished from language in Current Procedural Terminology (CPT) codes that specify assessment, e.g., 97755, Assistive Technology Assessment, which may be payable).

    Assessments can only be provided only by clinicians, because assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s).

    The assessment determines, e.g., changes in the patient's status since the last visit/treatment day and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgments about progress toward goals and/or determine that a more complete evaluation or re-evaluation is indicated. Routine weekly assessments of expected progression in accordance with the plan are not payable as re-evaluations.

    When is a screening more appropriate than an evaluation?

    Screening may be more appropriate than evaluation in some circumstances. For example, a patient develops an acute lateral epicondylitis from painting. The patient seeks physician attention who subsequently recommends that the patient see an occupational therapist. By the time the patient sees the PT/OT/SLP, she presents without any pain and has resumed all normal functional activities.

    Completing a screening interview of this patient should lead the therapist to determine that an PT/OT/SLP evaluation and treatment would not be medically necessary.

    • A screening is the gathering of information to determine the need for further evaluation by the clinician. The screening process may include a review of the patient’s medical record, a patient interview and observation of the patient.
    • Routine screening is not a billable service. Although some regulations and state practice acts require screening evaluations at specific intervals (such as at admission to a nursing home, or quarterly during the patient’s stay), for Medicare payment, evaluations must meet Medicare coverage guidelines.

    References

    Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services §220.3

    Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067

    Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing: A52773

    Outpatient Physical and Occupational Therapy Services: L34049

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