Medicare requires that documentation be completed at regular intervals and include specific information.
The information documented needs to be measurable and the goals functional. It should also delineate why your professional experience and intervention are required. In addition, the JCAHO standards are another source that defines documentation requirements.
An evaluation tool must be completed prior to the initiation of skilled therapy services. Medicare does not specify the actual tool the therapy professionals are required to complete for an evaluation. Regardless of the evaluation tool, in order to support services provided the facility must produce the following information for the Medicare Administrative Contractor:
- Physician order(s)
- Signed and dated certification by physician
- Date of evaluation
- Start of care date
- Medical diagnosis
- Treatment diagnosis
- Onset date
- Current level of function
- Prior level of function
- Treatment plan with long and short term goals
- Previous therapy administered to include:
- Diagnosis for treatment
- Modalities administered
- Progress notes detailing service provided for each date of service billed
- Grid reflecting service/HCPCS
Weekly progress notes are required to address the specific goals devised upon evaluation or goals modified during the course of the therapy program. Weekly documentation is required to identify the patient’s progress towards goals outlined on the evaluation. This documentation supports medical necessity for ongoing intervention as well as supports the services provided. The lack of this essential documentation may lead the Medicare Administrative Contractor to determine that services are not reasonable or necessary for the beneficiary.
Progress notes are most supportive with positive and proactive language versus focusing on negative aspects of the therapy programs and reduced outcome. Listing barriers to achieving set program goals is only pertinent when the note has descriptions of steps taken to aid the patient in overcoming barriers.
The use of progress notes is the therapist’s only way to communicate to a Medicare reviewer that a patient benefited from therapy. Progress notes should contain information regarding: functional goals; evidence of skilled service; and changes in levels of independence.
Daily notes should include evidence of skilled service and the patient’s response to the treatment. Weekly and monthly progress notes should contain all the above as well as comparative data. Medicare guidelines require that information regarding changes in level of independence be addressed at least weekly.
Explanation of Abbreviations commonly used in Rehab Charting:
Active Assistive Range of Motion
Activities Daily Living
Ankle Foot Orthosis
Above Knee Amputation
Assistive Listening Device
Anterior Lateral Sclerosis
Active and Passive
Active Range of Motion
Two Time a Day
Below Knee Amputation
Bilateral Upper Extremity
Certified Occupational Therapy Assistant
Cerebral Vascular Accident
Short Wave Diathermy
Full Weight Bearing
Knee Ankle Foot Orthosis
Large Based Quad Cane
Long Leg Cast
Left Lower Extremity
Long Term Goals
Left Upper Extremity
Narrow Based Quad Cane
Open Reduction Internal Fixation
Occupational Therapist Registered
Progressive Resistive Exercise
Passive Range of Motion
Physical Therapy Assistant
Pick Up Walker
Partial Weight Bearing
Right Lower Extremity
Restorative Nursing Aide
Range of Motion
Right Upper Extremity
Stand By Assist
Small Based Quad Cane
Short Leg Cast
Speech Language Pathologist
Short of Breath
Social Service Worker
Transcutaneous Electrical Neural Stimulation
Total Hip Arthroplasty
Total Hip Replacement
Transient Ischemic Attack
3 Times a Week
Total Knee Replacement
Toe Touch Weight Bearing
Weight Bearing As Tolerated
Within Functional Limits
Within Normal Limits
COMMONLY DENIED TREATMENTS
- Activities and exercises to promote overall improvement, general conditioning or endurance without a specific functional gain.
- Exercise and activities which can be administered by non-skilled persons.
- Duplicating services as when two disciplines provide the same treatment for the same reason.
- General range of motion exercise not related to a specific, measured loss of function that can be regained with therapy.
- Group treatment with group goals and not specific individual treatment goals.
- Hot packs without any other modality or procedure, commonly referred to as “feel good” hot packs.
- Limited learning potential for the stated goals.
- Long term maintenance therapy without the training of caregivers to continue with a program.
- Poor or fair rehabilitation potential. The lowest potential allowable is “Good for goals as stated”.
- Ongoing routine training in self care after initial instruction period and improved skills have been taught.
- Passive range of motion without any other procedure or modality.
- Repetitive services or treatment with no measured progress.
- Routine self care training and mobility where self care function would return spontaneously and safely without a skilled therapist.
- Routine assistance with ambulation that can be performed by an unskilled person.
- Therapy evaluations and treatment for rehabilitation candidates without the potential to achieve stated goals.
- Reevaluations unless a significant change has occurred.
- Treatment of degenerative, chronic or old (more than six months) onset diagnoses where no functional potential exists.
- Treatments rendered without a physician’s order.
- Where poor cognitive status would prohibit new learning or adequate participation in the therapy process for the stated goals.
- When treatment is unsubstantiated with specific and measurable baseline evaluation information.