Question: I work in an outpatient private practice setting and I have a question concerning Medicare documentation. We have designed a daily note format with check boxes for convenience where possible as well as space for hand-written notation. What is the minimum requirement in a daily note for subjective/objective data? Is it enough to say "improving" in subjective? Does there need to be a measurement of strength/ ROM each visit, or documentation of some functional deficit each visit in the objective portion? As you know, with a patient who is status post TKR or RTC repair, changes from visit to visit can be minimal. Any advice would be gratefully accepted.
Answer: In the Coverage Manual, IOM Pub. 100-02, Chapter 15, §220.3. E. Treatment Note: it reads "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 the services in order to justify the use of the billing codes on the claim form. Documentation is required for every treatment day, and every therapy service. The format shall not be dictated by the contractor and may vary depending on the practice of the responsible clinician and/or clinical setting." It continues, "The Treatment Note is not required to document medical necessity or appropriateness of the ongoing therapy services. Descriptions of skilled interventions should be included in the plan or progress note and are allowed, but not required daily."
CMS has also identified that you may write a daily progress note in a different way. Also in §220.3, under D. Progress Report it states "Elements of the Progress Reports may be written in the treatment Notes if the provider/supplier or clinician prefers. If each element required in the Progress Report is included in the Treatment Notes at least once during the progress Report Period, then a separate Progress Report is not required."
Now, in reference to the subjective statement of "improving," CMS and its contractors have indicated that this is essentially a meaningless term. If you want to show that the patient is improving, then identify WHAT exactly has improved, such as ROM, strength, gait, balance, or other measure in a short term goal, using the same objective measure that was used on the evaluation.
Question: You may have answered this a hundred times in the past but I need some clarification regarding progress notes. Is a progress note only required every 10th visit only for Part B or also for Part A Medicare patients?
Answer: There are absolutely no guidelines from CMS as to what it expects in terms of documentation for any Part A institution such as hospitals, SNFs and HHAs. So the answer is, YES, the progress note by the 10th visit is only required for Part B. However, standards of practice, facility policies and procedures and your State Practice Act may require progress notes that meet specific timeframes. Having worked in the SNF arena for many years, we know that it has become a pretty well accepted standard for weekly progress notes to be written in SNF.
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.