In pursuing all possible educational opportunities relevant to the implementation of the Therapy Caps Exception Process, the Centers for Medicare & Medicaid Services (CMS) has requested that contractors publish documentation guidelines and examples as defined in the online manuals.

The following information has been provided directly from CMS Online Manual 100-02, Chapter 15, §220.3.5:

Documentation Requirements for Therapy Services
(Rev.46, Issued: 02-13-06, Effective: 01-01-06, Implementation: 03-13-06)  

A. General
B.
Therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services. Documentation must be legible, relevant and sufficient to justify the services billed. In general, services must be covered therapy services provided according to the requirements in Medicare Manuals.

These guidelines identify the minimal expectations of documentation by providers or suppliers or beneficiaries submitting claims for payment of therapy services to the Medicare program. Additional documentation not required by Medicare is allowed at the provider’s discretion. For example, the therapist may chose to document requirements of state or local laws, professional guidelines or the individual practice or facility. The therapist may choose to include narratives that specifically justify the medical necessity of services when those services are reviewed.

Medicare requires that the services billed be supported by documentation that justifies payment. Documentation must comply with all legal/regulatory requirements applicable to Medicare claims.

Contractors shall consider the entire record when reviewing claims for medical necessity so that the absence of an individual item of documentation does not negate the medical necessity of a service when the documentation as a whole indicates the service is necessary. Services are medically necessary if the documentation indicates they meet the requirements for medical necessity including that they are skilled, rehabilitative services, provided by clinicians (or qualified professionals when appropriate) with the approval of a physician/NPP, safe, and effective (i.e., progress indicates that the care is effective in rehabilitation of function).

C. Documentation Required
These types of documentation of therapy services are expected to be submitted in response to any requests for documentation, unless the contractor requests otherwise:

• Evaluation /and certified Plan of Care (may be one or two documents). Include the initial evaluation and any reevaluations relevant to the episode being reviewed;
• Certification (physician/NPP approval of the plan required 30 treatment days after initial treatment, or delayed certification);
• Progress Reports (when treatment exceeds 10 treatment days or 30 calendar treatment days/one month, whichever is less);
• Treatment Encounter Notes (may also serve as Progress Reports when required information is included in the notes); and
• For therapy cap exceptions, records justifying 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 use of the KX modifier.

Contractors shall not require more specific documentation unless other Medicare policies require it. Contractors may request further information to be included in these documents concerning specific cases under review when that information is relevant, but not submitted with records.

For Medicare purposes, dictated documentation is considered completed on the treatment day it was dictated. The qualified professional may edit and electronically sign the documentation at a later date. The date of the documentation is relevant only for the plan of care. However, contractors may require that treatment encounter notes and progress reports be dated within one week of the last date of treatment reported in the evaluation, Progress Report or Treatment Encounter Note.

Justification for treatment must include 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. 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.

In documenting records, clinicians must be familiar with the requirements for covered and payable outpatient therapy services as described in the manuals. For example, the records should justify:

• The patient is under the care of a physician/NPP;
• Physician/NPP care shall be documented by physician certification (approval) of the plan of care; and
• Other evidence of physician involvement in the patient’s care may include, for example: order/referral, conference, team meeting notes.
• Services require the skills of a therapist.
• Services must not only be provided by the clinician or qualified personnel, but they must require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that other staff, caretakers or the patient cannot provide independently. This may be documented, for example, by the clinician’s descriptions of their skilled treatment, the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.
• A therapist’s skill may also be required for safety reasons, if an unstable fracture requires the skill of a therapist to do an activity that might otherwise be done independently by the patient at home. Or the skill of a therapist might be required for a patient learning compensatory swallowing techniques to perform cervical auscultation and identify changes in voice and breathing that might signal aspiration. After the patient is judged safe for independent use of these compensatory techniques, the skill of a therapist is not required to feed the patient, or check what was consumed.

Evaluation/Reevaluation and Plan of Care
The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings and subjective patient self-reporting based on the guidelines of the American Physical Therapy Association, the American Occupational Therapy Association, or the American Speech-Language and Hearing Association. Only a clinician may perform an initial examination, evaluation, reevaluation and assessment or establish a diagnosis or a plan of care.

Evaluation shall include:

• A diagnosis (where allowed) and description of the specific problem to be evaluated and/or treated. For PT and OT, be sure to include the body part evaluated. Include all conditions and complexities that may impact the treatment.
• A description might include, for example, the premorbid function, date of onset, and current function;
• Objective measurements, preferably standardized patient assessment instruments and/or outcomes measurement tools related to current functional status, when these are available and appropriate to the condition being evaluated;
• Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools; and
• A determination that treatment is not needed, or, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.

When an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/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. Therefore, when evaluation is the only service, a referral and evaluation are the only required documentation.

Reevaluations shall be included in the documentation sent to contractors when a reevaluation has been performed. See the definition in section 220. Reevaluations are usually focused on the current treatment and may not be as extensive as initial evaluations. Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation. A reevaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services. A formal re-evaluation is covered only if the documentation supports the need for further tests and measurements after the initial evaluation. Indications for a reevaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care.

Reevaluation may also be appropriate at a planned discharge. A reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services. Reevaluation requires the same professional skills as evaluation. Current Procedural Terminology does not define a reevaluation code for speech-language pathology; use the evaluation code.

See section 220.1.2 for requirements of the plan. The evaluation and plan may be reported in two separate documents or a single combined document.

Progress Report
The Progress Report provides justification for the medical necessity of treatment. For Medicare payment purposes, information required in Progress Reports should be provided at least once every ten treatment days or once during the interval, whichever is less. Objective measures of progress should be included when available.

Progress Reports may be provided more often than required when the clinician or qualified professional judges them appropriates. If reports are written more frequently, a qualified professional may write some, but not all, reports in the interval. Elements of interval reports may be written in the encounter notes daily if the provider/supplier or clinician prefers. If each element required in a Progress Report is included at least once during the interval in the encounter notes, then a separate Progress Report is not required.

A clinician must personally perform or actively participate in at least one treatment session during the interval of treatment. Verification of the clinician’s supervision or treatment shall be documented by the clinician’s signature on the treatment encounter note and/or the Progress Report. A clinician must complete a Progress Report at least once during each interval of treatment. Alternately, the information required from the qualified professional must be included at least once during the interval in treatment encounter notes.

When unexpected discontinuation of treatment occurs, contractors shall not require a qualified professional’s interval report for the incomplete interval. Determine the necessity of services based on the delivery of services as anticipated in the plan and encounter notes. When discontinuation of treatment is expected during an interval (i.e., it is anticipated in the plan of care or in either interval or daily encounter notes) a discharge note is required.

The discharge note shall be an interval note covering the period from the last interval note to the date of discharge. At the discretion of the clinician, the discharge note may include additional information, for example, it may summarize the entire episode of treatment, or justify services that may have extended beyond those usually expected for the patient’s condition. Clinicians should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed. The record should be reviewed and organized so that the required documentation is ready for presentation to the contractor if requested.

Content of Assistant Progress Report
The evaluation and plan of care are considered incorporated into the Progress Report, and information in them is not required to be repeated in the report.

Progress Reports written by assistants supplement the reports of clinicians and shall include:

• Date of the beginning of the interval that this report refers to;
• Date that the report was written (must be during the interval;
• Signature, or for dictated documentation, the identification of the qualified professional who wrote the report and the date on which it was written or dictated;
• Objective reports of the patient’s subjective statements, if they are relevant.

• Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occur. Note that assistants may not make clinical judgments about why progress was or was not made, but may report the progress objectively.

Descriptions shall make identifiable reference to the goals in the current plan of care. Since only long-term goals are required in the plan of care, the interval report may be used to add, change or delete short-term goals or to delete completed long-term goals.

Assistants may add or change short-term goals only under the direction of a clinician. When short-term goal changes are dictated, report the order, clinician’s name and date.

Clinicians verify these changes by co-signatures on the report or in the clinician’s interval report. (See section 220.1.2(C) to modify the plan for changes in long term goals.) If a time interval for the treatment is not specifically stated, it is assumed that the goals refer to the plan of care active for the current interval of treatment. If a body part is not specifically noted, it is assumed the treatment is consistent with the evaluation and plan of care.

Any consistent method of identifying the goals may be used. Preferably, the long-term goals may be numbered (1, 2, 3, etc.) and the short-term goals that relate to the long-term goals may be numbered and lettered 1.A, 1.B, etc. The identifier of a goal on the plan of care may not be changed during the episode of care to which the plan refers. Add new goals with new identifiers or letters. Omit reference to a goal after a clinician has been reported it to be met, and that clinician’s signature verifies the change.

Content of Clinician (Therapist, Physician/NPP) Progress Reports
In addition to the requirements above for notes written by assistants, the interval report of a clinician shall also include:

• 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 clinician for certification of the next interval of treatment.

A reevaluation should not be required before every Progress Report routinely, but may be appropriate when assessment suggests changes not anticipated in the original plan of care.

Treatment Encounter Note
Documentation is required for every treatment day, and every therapy service. The Treatment Encounter Note must record the name of the treatment, intervention, or activity provided, the time spent in services represented by timed codes, the total treatment time (including the untimed code services) and the identity of the individual providing the intervention. The format may vary depending on the therapist and the clinical setting.

The purpose of the Treatment Encounter Note is not to document the medical necessity or appropriateness of the ongoing therapy services (although the encounter note may be used to establish medical necessity if it fulfills the requirements of the Progress Report). The purpose of these notes is simply to create a record of all encounters and skilled interventions that are supervised or provided by qualified professionals to justify the use of billing codes on the claim. Descriptions of skilled interventions should be included in the plan or the interval notes and are allowed, but not required daily. Non-skilled interventions need not be recorded in the encounter notes as they are not billable. However, notation of non-skilled treatment or report of activities performed by the patient or non-skilled staff may be reported voluntarily as additional information if they are relevant and not billed.

Documentation of each treatment encounter will include the following required elements:

• Date of treatment;
• Total timed code treatment minutes and total treatment time. The amount of time for each specific intervention/modality provided to the patient is not required, as it is indicated in the billing, but the billing and the total timed code treatment minutes must be consistent. See CMS IOM, Pub. 100-04, chapter 5, section 20.3 for description of billing timed codes. Identification of each specific intervention/modality provided and billed, for both timed and untimed codes. Frequency and intensity of treatment and other details may be included in the plan of care and need not be repeated in the treatment encounter notes unless they are changed from the plan; and
• Signature and professional identification of the qualified professional who furnished or supervised and list of each person who contributed to treatment during that encounter (i.e., the signature of Kathleen Smith, LPT, supervisor, with notation of the assistance of Judy Jones, PTA, when permitted by state and local law).

If a treatment is added or changed under the direction of a clinician during the treatment days between the interval progress reports, the change must be recorded and justified on the medical record, either in the treatment encounter note or the progress note, as determined by the policies of the provider/supplier. New exercises added or changes made to exercise program help justify that the services are skilled.

Documentation of each treatment encounter may also include the following optional elements to be mentioned only if the qualified professional recording the note determines they are appropriate and relevant. If these are not recorded daily, any relevant information should be included in the progress report.

• Patient self-report;
• Adverse reaction to intervention;
• Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist, etc.);
• Significant, unusual or unexpected changes in clinical status;
• Equipment provided; and/or
• Any additional relevant information the qualified professional finds appropriate.

The billing was for 1 unit of ultrasound, one of therapeutic exercise and one gait training. It is assumed the ROM was less than 8 minutes and did not qualify for billing. It is assumed the patient tolerated the treatment unless there is a note to the contrary. See CMS IOM Pub. 100-04, chapter 5, section 20.2 for instructions on how to count minutes.

It is important that the total number of timed treatment minutes support the billing of units on the claim, and that the total treatment time reflects services billed as untimed codes.

Contractors shall not count each minute for each therapy service relative to each billed treatment code, but shall ascertain that the total number of minutes of treatment for services represented by timed codes is consistent with the number of units billed for those services and that the total minutes of treatment, including untimed codes, is consistent with the documentation that the services were provided for a reasonable amount of time. For example, if the timed code minutes equal 40 and the total treatment time is 45 minutes, it is appropriate that three timed codes are billed but unlikely that two untimed services were appropriately provided.

Page Posted: 04/14/06