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Effective April 1, 2015, Palmetto GBA is requiring additional therapy documentation for all Additional Documentation Request (ADRs) that contain continued therapy services into the subsequent episode. In addition to the re-evaluations and visit notes completed during the requested time frame, the agency will also be required to include the initial therapy evaluation plus the therapy re-evaluation performed immediately prior to the episode under review.

Example: The agency receives an ADR request for a patient’s 3rd consecutive episode. The initial therapy evaluation completed during the first episode and the therapy re-evaluation (within the 5 day window) completed immediately before the episode requested would be required to be submitted plus all of the therapy documentation during the ADR time frame.

From all appearances, Palmetto will be looking for consistency and documentation to support continued therapy services as medically necessary. How will the therapy documentation stand up under the increased focus? A few key points to review with your therapy and nursing staff:

  • The patient’s condition and functional limitations must remain consistent during a relative time frame. For example, SN completed a SOC and the PT completed their evaluation the following day. The SN marked M1860 as 1 in the SOC and PT documented the patient required CGA to safely ambulate. Are visiting the same patient? The PT evaluation and documentation must support the OASIS responses. Consistent documentation to reflect the patient’s physical and mental condition/deficits is crucial to support medical necessity and/or homebound status, and coordination of care.
  • All therapy goals must be related to a functional deficit and also be objective and measurable. Look at the therapy evaluation and compare their POC goals to the documentation. Are they related to a documented deficit? Are they objectively measurable?
  • All therapy goals must contain short and long term goals. Recently, we have received reports that Palmetto has cited agencies for not designating goals as short or long term EVEN if the goals contained a time frame. Therapy POCs containing goals to be achieved within various times, such as “Independent in HEP in 2 weeks” and “Ambulate 100 feet with RW in 8 weeks” must also identify these goals as ‘short’ or ‘long’ term goals.
  • Did the therapist or therapist assistant include documentation to support why their presence was required in each visit note? The Medicare Benefit Policy Manual states “To be covered as skilled therapy, the services must require the skills of a qualified therapist and must be reasonable and necessary for the treatment of the patient’s illness.” Most therapy notes include what the patient performed during the visit, but does the documentation also include the skill that the therapist provided? Documentation including specific education, training, verbal cues, etc. help to support medical necessity for therapy
  • Each visit note must include documentation, in objective and measurable terms, to address the therapy goals. Terms such as “increase”, “improving”, or arrows are not measurable and should be avoided. Objective, measurable terms such as the feet ambulated, level of assistance required, ROM measurements, etc. support the goals and should be clearly evident in each therapy visit note.
  • Each discipline must obtain the physician’s approval for their POC and clearly document obtaining the physician’s approval including the name of the physician. Documentation to support the clinician contacted the physician and the physician approved the POC will provide coverage for the visits completed after the evaluation and prior to the physician’s dated signature in the POC.
  • The therapist must clearly document the need for continued therapy services and what the PT plans to focus on and accomplish in each assessment or re-evaluation. In the re-evaluations the therapist must be able to document the improvement that has already been made and the potential for the patient to continue to improve. Also, understand that if the therapist feels that any changes need to be made to the plan of treatment, including updating goals, there must be a physician order, signed and dated by the physician, to update the plan of treatment.
  • Please keep in mind the reviewer will not “know” this patient. The staff may “know” the patient very well and be complacent with the documentation. Keep in mind if it is not documented, you know the result…

The Medicare Benefit Policy Manual contains a wealth of information to assist agencies with documentation requirements as well as numerous guidelines. See the links below to the PGBA update and the Medicare Benefit Policy Manual.

Palmetto GBA update

Medicare Benefit Policy Manual