Question: I am a physical therapist working in skilled nursing homes. One of my former employers, a nationally known rehab company, prohibited the staff from using orders that included a range of frequency or duration. They told us that it was against Medicare regulations. For example, rather than the order stating "Physical therapy 5-6 days/week for 4-6 weeks" the order had to say "Physical therapy 5 days/week for 6 weeks." I have not been able to locate any specific written rule, regulation or recommendation confirming this statement. Please provide guidance based on APTA recommendations, best practice and/or federal/CMS rules/regulations.
Answer: The most recent regulations for documentation under Medicare Part B, Section 220.1.2 - Plans of Care, B. Contents of Plan states
"The plan of care shall contain, at a minimum, the following information required by regulation.Long term treatment goals; and Type, amount, duration and frequency of therapy services."
It then goes on to describe what is required for each part. For long term treatment goals, the new regulations state "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."
For amount, the regulations state "this refers to the number of times per day the patient is to be treated." It says that frequency "refers to the number of times in a week the type of treatment is to be provided" and that duration is "the number of weeks, or the number of treatment sessions, for THIS PLAN of care."
Under the old guidelines for Part B, Medicare stated that information in a therapy order could not be a range but had to be specific. For example, the order had to say something like "Physical therapy 3x/week for 6 weeks."
Unfortunately, as far as Part A services go, we have no direction as to documentation of therapy orders. Under Part A, the concern about using a range of frequency and/or duration is that the use of a range is often used for the convenience of the therapist or facility (because of staffing issues), rather than the needs of the patient.
Medicare believes that there is an expectation that, based on the knowledge, skills and judgment of the therapist, the therapist should be able to make a prediction of the frequency and duration of services. The prediction is based upon the identified needs of the patient, taking into consideration not only the condition being treated but other factors such as age, co-morbidities, medications and other factors.
If it is found that a patient cannot tolerate frequency at the amount that was predicted, then the therapist can reduce the frequency accordingly, and identify the reason for reducing the frequency in the documentation. The occasional misjudgment of the frequency of treatment that a patient will tolerate will not be a problem on Medicare Medical Review.
The duration of treatment under Part A should always documented as the length of time the therapist believes it is going to take to meet the long term goals for discharge from therapy services.
Pauline Franko is owner and principal lecturer for Encompass Consulting & Education, LLC, a rehabilitation consulting and education company 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 a principle 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