In this seventh in our series of blogs asking the question “Is your practice ready for a Medicare audit?” we discuss Treatment Notes.
“If you did not write it, you did not do it.” This is usually one of the first lessons we learn as clinicians. Simply stated, Treatment Notes are where you write what you did. These notes are the source document auditors look to when reconciling what was done vs. what was billed. We have seen audits swing on the quality of the Treatment Notes many times.
Medicare requires that the clinician create medical record documentation for every treatment day. Sufficient detail must be provided for every therapy service provided to justify the use of codes and units on the claim. From a clinical perspective, these notes provide a chronology of precisely what you did for the patient. From a financial and audit risk management perspective, this is your opportunity to clearly document exactly what you did during a treatment session to justify the codes you billed.
The treatment note must include the following information:
Date of treatment
Identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding
Record of the total time spent in services represented by timed codes under timed code treatment minutes
Record of the total treatment time in minutes, which is a sum of the timed and untimed services
Signature and credentials of each individual(s) that provided skilled interventions
In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:
Patient comments regarding pain, function, completion of self-management/home exercise program (HEP), etc.
Significant improvement or adverse reaction to treatment
Significant, unusual or unexpected changes in clinical status
Parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight
Description of the skilled components of the specific exercises, training, or activities
Instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions
Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist)
Communication with patient, family, caregiver
Equipment provided; and
Any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.
In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary, a family member, another caregiver or unskilled personnel.
Use of Grids, Flow Sheets or Checklists
Many practices use a grid, flow sheet or checklist form to record exercises/activities performed. It is a convenient way to document exercise names (e.g. pulleys, UBE, TKE, SLR) resistance levels, weights, reps, etc. It also provides a clear picture of the patient’s progress from session to session. However, this alone does not establish that skilled therapy services have been provided. This is especially true when the exercises have been performed over multiple sessions. The therapist should periodically document the skilled components of the exercises so that they do not appear repetitive and therefore unskilled.
Similarly, documenting functional activities performed (e.g., “ambulated 35 feet with min assist”, “upper body dressing with set up and supervision”) does not demonstrate that skilledtreatment was provided.The therapist should periodically document the skilled components/techniques employed to improve the functional activity.
You must include the signature and credentials of the qualified professional/auxiliary personnel who provided the services each day.
Documenting Treatment Time
CMS requires that providers record Timed Code Treatment Minutes and Total Treatment Time for each session. They want providers to use this terminology exclusively. Do not use other language or abbreviations as these may make medical review more difficult for auditors.
Timed Code Treatment Minutes refer to those procedures that are provided in timed intervals and include many of the most commonly performed items (Therapeutic Exercise, Manual Therapy, Therapeutic Activity, etc.). These are billed in 15-minute intervals and follow the Eight Minute Rule.
Total Treatment Time refers to the actual time spent treating the patient and includes both timed and untimed codes. Times should not be rounded up to 15-minute increments; the actual treatment time must be recorded.
CMS offers the following examples:
A treatment session includes:
15 minutes therapeutic exercise (97110) timed code
20 minutes therapeutic activities (97530) timed code
25 minutes unattended electrical stimulation (G0283) untimed code
The time documented in the treatment note would be:
Timed Code Treatment Minutes: 35 minutes
Total Treatment Time: 60 minutes
A second treatment includes:
30 minute OT initial evaluation is completed (97003), untimed code
20 minutes fluidotherapy (97022) untimed code
The time documented in the treatment note:
Timed Code Treatment Minutes: 0 minutes
Total Treatment Time: 50 minutes
Time spent on the following items should not be included when computing total treatment time:
Waiting for treatment to begin
Waiting for equipment
Performing unskilled or independent exercises or activities.
In our next Blog we will discuss Discharge Notes.
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 or visit our website www.gencohealthcare.net.