About one year ago, UHC issued a policy requiring that daily notes include time in and out for commercial patients. (You should note that UHC Medicare Advantage plans follow Medicare documentation requirements.)
UHC has revised its policy for commercial patients so that time in and out is no longer required. Instead, UHC requires each daily note to include “[a]ccurate documentation of the length of treatment session.” You should be able to satisfy this requirement by recoding total treatment minutes in the same manner as you do for Medicare patients.
UHC’s policy change is effective for dates or service on and after July 1, 2024. UHC’s policy now requires daily notes to include the following:
- Date of treatment
- Specific treatment(s) provided that match the CPT code(s) billed
- Accurate documentation of the length of treatment session
- The individual’s response to treatment
- Skilled ongoing reassessment of the individual’s progress toward the goals
- All progress toward the goals in objective, measurable terms using consistent and comparable methods
- Any problems or changes to the POC
- Member or caregiver involvement in and feedback about home program activities
- Signature and date of the treating provider
And although UHC has not changed its policy regarding what needs to be included in a plan of care for a commercial patient, you should note that the POC must include all the following:
- Functional or physical impairment; and
- Short and long-term therapeutic goals and objectives:
- Treatment goals should be specific to the member’s diagnosed condition or functional or physical impairment
- Treatment goals must be functional, measurable, attainable and time based
- Treatment goals must relate to member-specific functional skills
- Treatment frequency, duration, and anticipated length of treatment session(s)
UHC’s revised commercial policy can be found at here.