KEYS TO EFFECTIVELY DOCUMENTING OUTPATIENT THERAPY (AND AVOIDING DENIALS)
Webinar Questions and Answers
The following are questions submitted during a June 26, 2019 PT Management Support webinar on PT/OT documentation with answers.
Q: Do providers need to specify what body part they are treating under the treatment provided? In other words, do they need to state they are treating the R knee, or as long as they state what leg/arm they had them do the exercises etc. on, are they OK?
A: No, the narrative information in the daily note or progress note should explain the focus of treatment. This is not to say if several body parts are being treated, the therapist may want to document specific interventions provided. For example, if a therapist is treating the knee and shoulder based on the initial evaluation and is providing electrical stimulation, it would be important to document if the ES was provided to the shoulder, knee or both during each treatment session to support medical necessity and for liability reasons.
Q: Some providers do not document specific aggravating factors that link to their goals. Do these aggravating factors need to be addressed in the eval?
A: Aggravating factors should be included in the evaluation as comorbidities, activity limitations or participation restrictions. They should be incorporated into general goals. Documenting aggravating and alleviating factors can support the complexity in treating the patient.
Q: If an outpatient is admitted to the hospital (for an overnight stay), does this require the therapist to discharge and perform a new evaluation to continue treatment?
A: No. You only need to perform a new eval if the presentation of the patient changes.
Q: If the MD does not date the POC but it is faxed to us, can the time stamp be proof of timely signature?
Q: If you have a patient whose Medicare POC expired one day prior to the therapy visit and you see them but are actually discharging them, do you need to do a re-eval to extend the Medicare POC one day, or can you simply do the treatment note/discharge summary? We have always done the re-eval, but I am curious to see if the therapist could just do the note?
A: If you are going to bill for the one day past the expired POC, then you need to complete an updated plan of care and have it re-certified. The first POC only allows you to charge for therapy visits within the treatment period approved by the physician up to 90 days. However, you are not required to do a re-evaluation with every extension of a POC. Under Medicare guidelines, a re-eval is medically necessary (and therefore payable) only if the therapist determines that the patient has had a significant improvement, or decline, or other change in his or her condition or functional status that was not anticipated in the POC.
Q: Do we need to document “pain” at each therapy visit? If so, is this a CMS standard?
A: You are not required to document pain; however, if pain is a limiting factor that is affecting performance of goals, it should definitely be documented. Because pain is a subjective report, often it is better to focus goals on objective measures while documenting functional activities being positively or negatively impacted by pain.
Q: Is there a time limit on the progress report? That is, should a PR be done every 10th visit or _____ days, whichever comes first?
A: CMS requires that a progress report be completed on or before every 10th visit. There is no other limit. But keep in mind that if you complete the first progress report for visit 8, you will need to do the next progress report no later than visit 18.