The CERT A/B MAC Outreach & Education Task Force, a partnership of all A/B Medicare Administrative Contractors, created this guide to educate providers on common documentation errors for outpatient rehabilitation therapy services. These widespread errors contribute to Medicare’s national payment error rate, as measured by the Comprehensive Error Rate Testing (CERT) program.
The leading cause of payment errors for therapy services is “insufficient” documentation in the medical records. Documentation is often missing the required elements as outlined in applicable local coverage determinations, JL LCD L27513 - Physical Medicine & Rehabilitation Services, Physical Therapy and Occupational Therapy and JH LCD L32710 - Therapy Services (PT, OT, SLP) and the CMS Internet Only Manual Pub. 100-02 Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230.
For example, a provider indicates in the medical record: “Plan of Care: We would like to see the patient three times per week to initiate exercises and modalities to decrease pain and increase range of motion, stretching, strengthening and function.” This plan is missing key elements to support the medical necessity of the service, such as measurable long term goals, the patient’s diagnosis, the proposed type, duration and frequency of services required to achieve each goal, or anticipated plan of discharge.
Additional widespread issues that result in “insufficient” documentation errors include:
The CERT A/B MAC Outreach & Education Task Force recommends providers carefully review the following documentation requirements and tips for ensuring complete and accurate medical records.
The plan of care shall contain, at minimum, the following information as required by regulation (42CFR§424.24 and 410.61 and MBPM, Chapter 15, Section 220.1.2(B)):
The plan of care shall be consistent with the related evaluation. The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources.
The legible signature and professional identity (e.g., MD, OTR/L) of the individual, who established the plan, as well as the date it was established, must be recorded with the plan. A physician or NPP must certify (and date) the plan of care (*note: for CORF services, NPPs may not order or certify therapy services). Certification may be established in the patient’s medical record through:
The purpose of treatment notes is to create a record of all treatments and skilled interventions that are provided and to record the time of the services to justify the use of billing codes and units on the claim. Documentation is required for every treatment day and every therapy service. Documentation of each treatment note must include the following required elements:
Claims for therapy services that are required to contain the non-payable G-codes and corresponding modifiers should include documentation of Functional Reporting in the medical record. Specifically, documentation of the non-payable G-codes and severity modifiers regarding functional limitations reported on claims must be included in the patient’s medical record of therapy services for each required reporting interval as outlined in the MBPM, Chapter 15, Section 220.4. Documentation of functional reporting must be completed by the clinician furnishing the therapy services. Therapists must also document his/her clinical judgment in the assignment of the appropriate severity modifier.
To find additional information regarding therapy and rehabilitation services, refer to the following resources on the CMS website:
Disclaimer: The CERT A/B MAC Outreach & Education Task Force is independent from the CMS CERT team and CERT contractors, which are responsible for calculation of the Medicare Fee-for-Service improper payment rate.