Do you know therapy Medicare documentation requirements? Take a minute before you answer. While you are thinking about your answer, here are some more teasers: do you have a copy of your Medicare Administrative Contractor’s (MAC) local coverage determination, (LCD) and is it current? Do you know the required and voluntary elements of the therapy plan of care? Do you know how minutes are to be recorded on the daily note? Do you know how to document functional limitation if the patient self-discharges? Hopefully you are not second guessing yourself. I am auditing charts today for a therapy provider (as their external auditor designated on the provider’s compliance plan). This provider uses an EMR, so the charts are easy to read, and it is a therapy EMR – which means that categories for major elements and requirements are teed up. However, the therapist still has to provide the information, so that means they need to know the documentation requirements.
Therapy Medicare Documentation Requirements – Help from the CERT Task Force
The Comprehensive Error Rate Testing Program (CERT) is charged with reviewing claims submitted to the MACs in order to determine the MAC’s paid claims error rate. So the fine folks at CERT are measuring the MACs, not the therapy providers. However when the CERT contractor notes that a therapy claim was paid in error after reviewing the documentation, the MAC is dinged on the error, and in turn the MAC turns to the provider to recoup the reimbursement “paid in error”. A CERT Task Force of Part A and Part B MACs has been meeting in order to, among other things, collaborate on and supplement educational offerings to providers in order to reduce the CERT error rate and improper Medicare payments. The CERT Task Force recently released an educational “scenario” indicating that the leading cause of payment errors for therapy services is “insufficient” documentation”. They note that the documentation is often missing the required elements (contained in the Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230). The report offers the following guidance to therapy providers:
Avoid CERT Errors: Tips to Improve Therapy Documentation:
- Ensure the medical records submitted provide proof the service(s) was certified and rendered.
- Ensure the medical records provide justification supporting medical necessity and that skilled services were needed.
- Create a complete plan of care, making certain to include your legible signature, professional identification (e.g., PT, OTR/L) and date the plan was established.
- Document when the plan of care is modified, including how it has been modified and why the previous goals were not met or could not be met.
- Confirm the plan of care is certified (recertified when appropriate) with physician/NPP legible signature and date.
- Clearly document, in minutes, the total time spent on timed-code treatment only and the total treatment time (including timed and untimed codes) in the patient’s record.
The detailed report should be considered mandatory review for all outpatient therapy practices (regardless of the setting). Add this to your compliance risk assessment, and review the report. Oh, by the way, I did not forget about my provider audit – they measured up pretty well against the CERT Scenario – of course there are a few suggestions to make in terms of…. well I will leave that for my audit report and metrics.
How do your risks stack up? Is your audit plan designed to assess these risks at your clinic?
Note: The Task Force Therapy Scenario was copied by author into a PDF document for ease of view.