Painting the Picture Through Therapy Daily Treatment Notes

As a follow-up to the previous blog post on therapy plans of care and Medicare certifications, I want to once again reference the CERT A/B MAC Outreach and Education Task Force’s online resource titled “Documenting Therapy and Rehabilitation Services” which highlights several areas CMS has identified as common documentation errors for outpatient therapy services.  Today, we will focus on daily treatment notes.  We will address progress reports and functional limitation reporting in a future post.

Minimum Requirements

As we review some of CMS’s key points regarding daily treatment notes, it is worthwhile to mention that many of these guidelines are a good rule of thumb to follow for all payers.  The daily treatment note is the therapist’s record of all treatments and skilled interventions that are provided to that patient for a particular date of service.  (Remember that “skilled” part as we are going to revisit this key element shortly.)  Furthermore, the time recorded in the daily note justifies the number of units billed for that day.

Per Medicare’s guidelines, documentation of each treatment note must include the following elements:

• Date of treatment
• Identification of each specific intervention/modality provided and billed (both timed and untimed codes)
• Total timed code treatment minutes and total treatment time in minutes
• Signature and professional identification of the qualified person who furnished the services

Some of these points are no-brainers, e.g. date and signature.  However, I often see therapists’ notes that do not include details about the treatment interventions provided that day or that do not include the total timed code minutes and/or the total treatment time.  In an audit, the failure of the clinician to provide details related to the treatment provided or the omission of the time spent performing timed code minutes and the total treatment time can and will most likely lead to a denial.

Treatment Minutes

While some payers may require the time spent on each procedure to be documented, Medicare requires only the documentation of the total of the timed code treatment minutes as well as the total treatment time which includes the minutes for both timed and untimed procedures.   I have seen firsthand several scenarios in which Medicare denied services for which the time was not documented.  Medicare will look at the time documented in determining if the total number of billed codes was appropriate.   The number of timed codes billed should not exceed what is justified in the documentation based on Medicare’s 8-minute rule.

Documentation of Skill

I could do an entire blog series on this one topic, but for today, I want to present just a few key points to remember which may help ensure payment for your services.  First, keep in mind that the daily note is a record of not only the patient’s activities but also the therapist’s interaction with the patient during the session.  This is where the “skilled” piece comes into play.  Too often, therapists just list what exercises the patient performed without including any information as to the therapist’s involvement in the session, such as verbal and/or tactile cueing, progression or modification of exercises, correction of technique, patient education, etc.  It is the documentation of this information which helps relate to the payer the skilled nature of the services provided rather than just a list of what the patient did during the session.  I frequently remind clinicians that the payer is not paying the patient to perform exercises in therapy but rather that it is paying the clinician to provide a skilled service.  Therefore, it is crucial to not only document the patient’s activities but also the skilled intervention on the part of the clinician.

In addition, it is important to provide details regarding the procedures or modalities performed including specific parameters as well as the rationale or clinical decision-making behind the selected interventions.   Documentation of this clinical reasoning can help the payer to better understand why you performed that electrical stimulation or how those manual therapy techniques will address the patient’s functional deficits.

Signatures

With most clinicians now documenting using EMR systems, getting proper signatures on a chart note isn’t as much of an issue anymore.  For any clinicians still handwriting their notes, though, it is important to make sure the signature is legible or, if illegible, that the signature is over the typed or printed name.  Providers may also maintain a signature log that can be submitted with any records request.  Stamped signatures are not considered acceptable by Medicare.

A common question I receive pertaining to signatures is in regard to the co-signing of the PTAs’ notes by the supervising therapist.  While some state practice acts and private payers may require co-signatures, Medicare does not require the supervising therapist to co-sign a daily treatment note written by a PTA.  Per the Medicare Benefit Policy Manual, the daily note must include the signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment. The signature and identification of the supervisor does not have to be on each treatment note, unless the supervisor actively participated in the treatment.  When the treatment is supervised without active participation by the supervisor, the supervisor is not required to co-sign the treatment note written by a qualified professional.

Painting the Picture

Medicare notes in its Benefit Policy Manual that the treatment note is not required to document the medical necessity or appropriateness of the ongoing therapy services.  The Progress Report is designed to address those areas.  However, daily treatment notes help the payer, be it Medicare or any other insurance carrier, to understand what is happening at each session as well as the skilled nature of the services provided.  I once heard a presenter make the analogy that the daily note is the receipt the clinician gives the payer for the payment of services rendered.  It is the responsibility of the clinician to paint a descriptive picture of each session in order to increase the likelihood that those services will be reimbursed.