Medicare ADVISOR Q&A

SNFs: Which Documents Need To Be Signed by a Physician?

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QUESTION: I am the rehab director at a SNF where we are contracted. The SNF has recently undergone an internal audit where many errors were found, and we are in the process of trying to remedy some of the problems and come up with plans of correction.

Last week, our medical records clerk went to a meeting, and one of the things she was told, which she brought back to me, is that not only do our plans of care have to be signed by a physician, but so do the actual OT/PT/ST evaluations as well as our progress notes. I have never heard of such a thing, and it really does not make sense. I would think that our progress notes especially would be meaningless to a physician. Medical records said that we will have to implement this new policy, unless I can find and show her where this is not necessary.

Has something changed or was she told inaccurate information? Could you help me find where in Medicare rules and regs it says which documents need to be signed by a physician? The last seminar I attended stated that only the plan of care must be signed off on by a physician. 

ANSWER: The only requirement for Part A SNFs is that the physician review and approve the plan of care developed by each discipline treating the patient. That is it!

There is no requirement to send the physician any other form of documentation -- either progress notes or the evaluation. It is entirely up to the facility to determine what kind of communication they want to send the physician for either informational and/or professional courtesy.

Once the physician has approved the plan, it is good for the duration of the plan; i.e., the length of time indicated in the duration. Once the duration of approval is reached, it's up to facility policy what happens next. Some facilities have a policy to update the plan and send that for approval for further care, while others will extend the existing plan for the additional time needed to achieve the LTG.

In the May 6, 2011 Proposed Rule, CMS stated: "Should the actual utilization of therapy services deviate significantly from the patient's plan of care, we expect the facility to update the plan of care to prescribe the new type, amount, frequency & duration of .therapy services.The revised care plan must outline the updated goals and the revised type (that is mode) [editor's note: here they mean individual, concurrent or group], amount, frequency and duration of.therapy services to be furnished to the patient.

DISCLAIMER: 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 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, PT, CEEAA, is owner of Encompass Consulting & Education LLC based in Tamarac, FL. The company specializes in Medicare seminars and webcasts as well as consulting and compliance training. Visit www.encompassmedicare.com. The company's "Direction on Demand" service specializes in providing the rehabilitation professional a clear, easy way to understand how to provide Medicare compliant services in the SNF and outpatient settings.

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