Therapy Documentation 101

February 3, 2020

We asked via Facebook for topics to write about and a reader requested an article on therapy documentation. It’s a very timely subject considering all of the scrutiny by CMS review contractors such as MACs, RACs, ZPICs, UPICs, etc. and the review choice demonstrations that started in Illinois on June 1st, Ohio on September 30th and will start in Texas on March 2nd. (If you’re not sure what these acronyms mean, check out the list of commonly used Medicare-related acronyms.)

Fundamental guideline

The most important thing to remember when documenting a therapy visit is to ensure that your therapy treatment note independently gives evidence of the skilled care you delivered. This means that your documentation provides clear support for the treatment being reasonable, medically necessary and requiring your skills as a therapist. That’s the bottom line but it’s also important to consider the rules and regulations and policies and procedures of the entities involved.

The payer

You should understand what information the payer wants to see in your documentation. For Medicare, most of the guidance you’ll need comes from the Medicare Benefit Policy Manual. Chapter 7 covers home health services, chapter 12 Comprehensive Outpatient Rehabilitation Facility services and chapter 15 other medical services including outpatient therapy. These go into some level of detail about the content of evaluations, visit notes, care plans, periodic reassessments, and doctor’s orders. For outpatient therapy, the following sections of Chapter 15 are worth taking a look at:

  • Section 220.1.2 which covers the contents of the Plan of Care for Outpatient Therapy
  • Section 220.1.3 which covers Certifications and Recertifications
  • Section 220.3 which covers other Documentation Requirements including Progress Reports and Discharge Summaries (Subsection D) and Treatment Notes (Subsection E)

Note that you can ignore the Functional Reporting section since that ended December 31, 2018. For additional Medicare coverage information, check out the CMS Local Coverage Determinations and Articles which give details about diagnosis and CPT codes as well as documentation expectations for certain kinds of treatments.

A good rule of thumb for payers other than Medicare is that if you are following Medicare guidelines and providing detailed evidence of your treatment and your patient’s response and progress, more likely than not you are fine. In most cases, the payer’s website will have a section for providers which will show coverage information specific to that payer. If you can’t find or access a manual, you can call the provider phone number on the back of the patient’s insurance card and verify whether there are additional criteria that need to be met when documenting your provision of care.

Your state

As a licensed clinician, you are expected to follow the guidelines for your state. In our State and National Resources for Clinicians article, we provided links to some of the popular state resources for practice acts and select programs. You can also contact your state Department of Public Health for clarification. Remember, whenever guidelines seem to contradict each other, you should follow the more restrictive requirement. For example, if federal guidelines say that a functional reassessment is to be performed at least every 30 days but your state regulations say 20 days, you would be required to follow the state regulation of every 20 days. It’s the responsibility of a licensed clinician to know and follow the state regulations that apply to their license type (generally referred to as your “scope of practice”).

Your facility

Whether you do visits for a home health agency (HHA), comprehensive outpatient rehabilitation facility (CORF), skilled nursing facility (SNF), acute care hospital or other entity, you’ll be required to comply with their policies and procedures. As mentioned above, whenever there is a discrepancy between any set of standards, you’ll always be expected to adhere the stricter one. So, to extend the example above, if you do home health visits for an HHA and that HHA has a policy that functional reassessments must be done at least every 7 days, you’ll be required to do them every 7 days. If the agency’s policy says every 60 days, you’ll be required to do a reassessment every 20 days because of the stricter state regulation.

Accrediting body

If your facility is accredited by an organization like CHAP, Joint Commission, ACHC, URAC, NCQA, CARF or COA among others you may be subject to additional documentation standards. Generally, it’s the facility’s responsibility to ensure that these requirements are incorporated into their policies and procedures. It’s also their responsibility to provide the essential training and ongoing in-services. If you have any questions about accrediting organization’s standards, please inquire within your agency.

The Wrap-Up

The good news is that once therapy documentation standards are established, they don’t tend to change much. Having familiarized yourself with Medicare and state guidelines for your clinical specialty and any facilities you work for, you are most of the way there. Make sure you review facility policies and procedures to round out your education. This review should have been included in your initial employee orientation. If it has been a while, or if your facility orientation didn’t include a policy and procedure review, ask a clinical manager or director of clinical services about reviewing them.

I’ll repeat the basic guideline stated in the beginning of this article that every progress note you write must stand on its own to provide evidence of skilled need and care provision and that it required your knowledge and skill set. You can’t assume that the person reviewing your documentation is going to have access to the whole clinical record and be able to derive context from there. If the patient must be homebound, then homebound status must be reported on each entry. If no significant progress has been made in the current visit but notable improvement has been made since the start of care, be sure to point it out. When conducting a therapy reassessment or progress report, make sure you include a summary of the condition of the patient at the last assessment and note your patient’s progress or explain the lack of progress and detail any revisions to the care plan to address any shortcomings.

therapyBOSS to the rescue

therapyBOSS will help you consistently produce therapy documentation that meets the compliance requirements from payers, states, facilities and more. It has a simple user interface that allows you to document your evaluations, treatment notes, progress reports and more with ease. Responses from prior visits can be copied over automatically to speed up your charting, letting you focus on your patients. therapyBOSS tracks the progress you document and uses this information to generate progress reports with very little intervention needed. It also includes many functional tests that can provide standardized measurements of progress throughout the treatment.

If you have any questions about what therapyBOSS can do for you, feel free to email or call us at 847-581-6400. You can also connect with us on Facebook.