Is Your Practice Ready for a Medicare Audit? – Part 8

In this eighth in our series of Blogs asking the question, “Is your practice ready for a Medicare audit?” We discuss Discharge Notes.

Though sometimes overlooked or hurried by clinicians, the Discharge Note is an important part of the overall documentation package. A thoughtfully prepared note can indicate to an auditor that the practice owner and management team fully understand that the medical documentation is more than simply a recording of exercises and modalities. Rather it is the bridge that connects the clinical aspects of patient care with the financial aspects of billing and collections.

The Medicare Program Manual states:

The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment… The discharge note shall be a Progress Report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge.

In the case of a discharge unanticipated in the plan or previous progress report, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified personnel.

The Discharge Note should include objective tests and measurements to demonstrate the progress made toward the specific goal(s) established in the Plan of Care and support the clinician’s decision to discharge the patient. This documentation should also explain the justification for the final “G Codes” and Modifiers selected.

The APTA suggests the following elements be included:

Current physical/functional status.
Degree of goals achieved and reasons for goals not being achieved.
Discharge/discontinuation plan related to the patient/client’s continuing care.
Examples include:
Home program.
Referrals for additional services.
Recommendations for follow-up physical therapy care.
Family and caregiver training.
Equipment provided
CMS considers the Discharge Note to be of particular significance in the overall medical documentation of an episode of care. They see this as a final opportunity for the therapist to justify the case for skilled therapy services and a chance to explain any unusual circumstances that impacted on the treatment episode.

The Medicare Program Manual states:

The discharge note may include additional information; for example, it may summarize the entire episode of treatment, or justify services that may have extended beyond those usually expected for the patient’s condition.

Clinicians should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed.

The record should be reviewed and organized so that the required documentation is ready for presentation to the contractor if requested.

And in LCD L26884 they comment:

The discharge note may be considered the last opportunity to justify the medical necessity of the entire treatment episode. Therefore, if a discharge summary has been completed, it may be prudent to submit it with any request of records for medical review, even if the claim under review is for a treatment period prior to the date of discharge.

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 or visit our website