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Tips and tools for rehab professionals

Rehab Regs, October 31, 2008

Objective documentation

Information concerning the modalities and procedures provided to the patient must be documented for every treatment. In 2006, the Centers for Medicare & Medicaid Services (CMS) significantly updated and continued to alter documentation requirements for Medicare patients. The requirements set forth by Medicare provide therapists with a high standard of documentation that most insurance companies find beneficial.

For Medicare patients, documentation is required for every treatment day and every therapy service. Medicare requires that the treatment note include the following:

• date of treatment.
• identification of each specific treatment or modality for both timed and untimed codes in language that can be compared to the claim in order to verify correct coding. Each service represented by a timed code must be noted, even if it is not billed. For example, ultrasound may have only been performed for seven minutes but you may not bill for it because you billed other codes that represented the appropriate time under the eight-minute rule.
• total timed code treatment minutes and total treatment time in minutes.
• signature and professional identification of the therapist providing/supervising the therapy and a list of each person who contributed to the treatment.
• optional elements in Medicare daily notes include patient self-reports, adverse reactions to treatment, consultation/communication with other providers, changes in clinical status, equipment provided, and any additional relevant information.

This tip is from HCPro’s book The How-To Manual for Rehab Documentation: A Complete Guide to Increasing Reimbursement and Reducing Denials.

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