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. My question is 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."
In reference to the subjective statement of "improving", CMS and its contractors have indicated that this is essentially a meaningless term. If you are using the SOAP format, make the "S" portion mean something as it relates to the patient's perception, it can be positive, indicating improvement or negative indicating a problem; e.g. Pt states that over the weekend, they were able to lift a bowl down from the shelf without pain or PT states that after the last treatment they were extremely tired.
Showing that the patient is improving should be identified in the "O" portion where you identify exactly WHAT has improved. Here you would include the tests and measures that you used in your evaluation and compare either back to the evaluation or to the last time it was measured, e.g. ROM, strength, gait, balance, or other measure.
Question: We have some differences of opinion among the staff regarding progress notes. Is a progress note only required every 10th visit only for Part B or also for Part A Medicare patients?
Answer: The answer is "YES" in regards to the progress note for Part B patients. The minimum requirement is by the 10th visit or 30 days whichever comes first.
The answer for Part A is "There are absolutely no guidelines from CMS as to what as exactly needed in terms of documentation. This applies for any Part A institution such as Hospitals, SNF and HHA. We know that we need to demonstrate that treatment occurred according to the coverage requirements for that site, that the services were skilled and the time that the patient was receiving skilled care. So here you look at standards of practice, facility policies and procedures and your State Practice Act to see what is required as it relates to progress notes and 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.
The answers provided are based on Medicare guidelines for what is payable under the Medicare Part A and Part B Benefit. As always, the provider should be aware of the other regulations that might supersede the Medicare payment guidelines such as the State Practice Act and the State Administrative Code. In any scenario, the practitioner must go with the most stringent requirement in order to be compliant. The information provided is current as of the time of publication.
Pauline M. Franko is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Consulting, Compliance Training and Seminars, based in Tamarac, FL. Visit Encompass's website at www.encompassmedicare.com to learn more about the services they provide. 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. You may contact the author through the Encompass website or by phone at 954-720-4087.