Question: I am a physical therapist in an SNF setting. Recently, I have been seeing an increased number of Medicare Part B patients and I am trying to catch up on all the new requirements. My question is regarding daily notes for Medicare Part B patients and what specifically needs to be included in it. Is it sufficient for a daily note to be a billing sheet, or does the note need to include the patient's name, daily minutes spent on either gait training, therapeutic activity, e-stim, etc. with total minutes at the bottom of direct one-on-one with appropriate units and therapist's initials? Do I need to also include a specific time period (such as 10:30-11:00) with it?
Answer: The regulations as to the documentation requirements for a daily treatment note can be found in the IOM Pub. 100-02: Chapter 15, §220.3 - Documentation Requirements for Therapy Services, subpart E. Treatment Note. You can access this manual through the CMS Website at www.cms.hhs.gov/manuals?IOM/list.asp
In the manual, CMS states that "The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of services in order to justify the use of billing codes on the claim." It goes on to say that "Documentation is required for every treatment day, and every therapy service. The format shall not be dictated by contractors and may vary depending on the practice of the responsible clinician and/or the clinical setting."
The regulation identifies that the following elements are required in each note.
1. Date of Treatment.
2. Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment. You must understand that the definition of a signature is a "legible identifier" and can be an original, a faxed or electronic signature but not a stamped signature. We have been made aware of situations when a claim has been denied because the signature has not been legible! CMS notes that the signature of the supervisor of a PTA is only required when providing treatment and is not required on every note.
3. Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding. This does not mean just a list of CPT codes as these are the billing mechanism for the skilled services provided.
CMS has identified that the description of the skilled interventions should be included in the plan or the progress reports and are allowed but not required daily. In documentation reviews that we have participated in. we have noted that a complete description of the skilled interventions to be provided are not always clearly identified in the plan and therefore, would need to be more accurately reflected in the daily note or progress report.
4. Total timed codes treatment minutes and total treatment time in minutes. Total treatment time includes the minutes for both timed and untimed codes. It does not include time for non-billable service minutes such as periods when the patient is waiting for equipment or performing non-skilled activities. You do not have to identify time started/time finished, as that time is shown in the total treatment time.
CMS has stated that "The amount of time for each specific intervention/modality provided to the patient may also be recorded voluntarily, but contractors shall not require it, as it is indicated in the billing. The billing and the total timed code minutes must be consistent." The last part of this statement refers to the billing requirements for timed units and can be found in IOM Pub.100-04, Medicare Claims Processing Manual, Chapter 5 - Part B Outpatient Rehabilitation and CORF/ORF Services, §20.2
5. Changes made to treatment plan, either by adding or changing interventions/modalities.
When this is done by the assistant under the direction of the therapist, the therapist can either co-sign those changes or include those changes in the progress report
6. Other optional inclusions for daily notes are patient self-report, adverse reaction to interventions, communication with other providers, significant/unusual/unexpected changes in clinical status, equipment provided, and any other "relevant" information
CMS identifies that the progress report is the documentation justifying the Medical Necessity of treatment. However, if all of the elements of the progress report are included in the daily notes during the progress report period, then a separate progress report is not required.
Pauline M. Franko, PT is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Consulting, Compliance and Training, based in Tamarac, FL. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. As an associate in Comprehensive Medicare Consultants, LLC, she is responsible for assisting with and directing compliance programs to Rehab Agencies. Danna Mullins is an associate and lecturer with Encompass. You may contact the authors through the Encompass website at www.encompassmedicare.com or by phone at 954-720-4087.