Is Your Practice Ready for a Medicare Audit? | Part Four

In this fourth in our series of Blogs asking the question “Is your practice ready for a Medicare audit?” we discuss The Plan of Care and the critical role we have seen it play in provider audits.

Therapy services shall be payable when the medical record and the information on the claim consistently and accurately report covered therapy services.  Documentation must be legible, relevant and sufficient to justify the medical necessity of the services billed.

In our previous blogs we discussed that the medical record must paint a picture of the patient’s impairments and functional limitations requiring skilled intervention; and describe the prior functional level to assist in establishing the patient’s potential and prognosis.  Based upon these findings and in keeping with established procedures and the clinical judgment of the therapist, the Plan of Care must:

• Describe the skilled nature of the therapy treatment to be provided;
• Justify that the type, frequency and duration of therapy being is medically necessary for the individual patient’s condition;

A separate Plan of Care is required for PT, OT and Speech if applicable.  Medicare requires that the following items be included:

Diagnosis: 

The diagnosis should be specific and as relevant to the problem being treated as possible. In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.Bill the most relevant diagnosis. 

Note:  This is where the challenge of implementing ICD 10 needs to get met head on.  The therapist is required to use the “most relevant diagnosis and . . . the code that best relates to the reason for the treatment.”  The specificity, laterality and granularity of the ICD 10 Code will reveal a great deal about the patient each time you bill.  Care must be taken to assure that the code(s) selected are consistent with the information recorded throughout the patient’s medical record.

Long Term Goals (LTG’s):  Based upon the findings in the Initial Evaluation, the patient’s prior level of function, and rehab potential the therapist determines the Long Term Goals for the patient.  As a practical matter, goals should be reasonable, measurable and attainable within a reasonable period of time.  Medicare specifies LTG’s should:

• pertain to the functional impairment findings documented in the evaluation;
• reflect the final level the patient is expected to achieve as a result of therapy in the current setting
• be realistic, and should have a positive effect on the quality of the patient’s everyday functions;
• be function-based and written in objective, measurable terms with a predicted date for achieving the goals.

Type of Treatment:

The type of treatment includes the type of therapy discipline operating under this Plan of Care (PT or OT) and should describe the types of treatment modalities, procedures or interventions to be provided.

Note:  Genco was recently called in to assist a legal team prepare a response to a multimillion dollar Medicare Audit.  A major issue was therapy services that were provided, billed and paid though were not included in the Plan of Care.  These claims were denied by Medicare and contributed significantly to the overpayment.

Amount of Treatment:

Refers to the number of times in a day the type of treatment will be provided. Where not specified, one treatment session a day is assumed.

Treatment provided more than one session per day per discipline will require additional documentation to support this amount of therapy. 

Frequency of Treatment:

Refers to the number of times in a week that the type of treatment is provided

Medicare expects that treatment more than two or three times a week to be a rare occurrence and that treatment frequency of greater than three times per week requires documentation to support this intensity.

Duration of Treatment:

Refers to the number of weeks, or the number of treatment sessions, for this Plan of Care.  Clinicians could also estimate the duration of the entire episode of care in this setting.

In our next Blog we will discuss Certifications and Re-certifications of the Plan of Care.  

Genco Healthcare helps practices achieve and maintain a culture of compliance.  We also assist Healthcare Attorneys in defending their clients who have been audited or subject to pre payment review.  Consequently, we have our finger on the pulse of precisely what Medicare’s expectations are when it comes to medical documentation.  Contact us by email:  David@Gencohealthcare.net.