Medical necessity is a big topic in our industry...
We now must justify our clinical decisions
while capturing treatment accurately and effectively.
Audits have become everyday industry concerns as we face the allegations of “inappropriately billed” claims.
There is an increased expectation to justify why we are providing services
and why our clinical expertise is needed. The standards have changed, the challenges mount, and patients still deserve the very best care.
Documentation is complicated – but it starts with avoiding these 10 costly and all-too-common pitfalls. 1. Missing signatures
One of the first areas auditors look at is the physician signature on therapist plans of care. Currently, most therapists fax the plan of care to the physician for a signature, receive the signed form, and then file it. 2. Medical Necessity
Therapists must prove the medical necessity of patients' therapy services, whether physical therapy, speech therapy, or occupational therapy. Therapists need to show why the patients require the skilled services of a licensed therapist to reach their maximal level of function. 3. Medicare Caps
Lack of medical necessity is often subjective and can be strengthened with addendums added to the original file.
Medicare patients can exceed the caps, but therapists' documentation must prove medical necessity due to the complexity of the patients' condition and their potential to make progress with a therapist. 4. Cloning
Another problem auditors look for in rehab documentation is cloning: when documentation has not been changed across therapy sessions. If therapists do not change any information, claims can get denied due to cloning. 5. Duplication of Services
Therapists must prove the patients’ therapy services require the skills of their discipline. If multiple disciplines are treating this patient, goals and treatment notes need to clearly reflect the different scope of practice between therapy services. 6. Patient Self-Discharge
For example, a problem would emerge if both PT and OT are working on standing balance, transfers, and functional mobility during the same time frame.
In therapy programs, some patients will simply stop going without notifying the therapist or rehab program. If therapists leave documents for the patient incomplete, such as without a discharge summary, the claims can be denied.7. Certification & Recertification
A patient can only be labeled as “AMA” (Against Medical Advice) when officially documented by their primary physician.
To receive reimbursement from Medicare Part B, patients need to be recertified by Medicare every 90 calendar days. Medicare Part A requires the physician to frequently sign and approve the Medicare certification form which certifies skilled therapy amongst other skilled services. If the physician fails to sign and date this form, the entire skilled length of stay may be denied.8. Overbilling or Inappropriate Use of CPT Codes & Modifiers
Charges where the treatment time does not match the units billed or requires an appended modifier. Overbilling or billing irregularity is considered fraud abuse with dire consequences if not corrected in a timely fashion.9. Unsupported ICD-10 Diagnoses
When documenting the plan of care, a therapist must choose the medical and/or treatment diagnoses that most reflect the reason for therapy. Oftentimes hospital admitting diagnoses are used, which typically do not require therapeutic interventions as the standards of practice.10. Incomplete Medical Records
If a medical claim is being reviewed, it is critical to include all required documentation and supportive documentation that has been requested. If progress notes are incomplete or missing, the entire claim or portions of the claim may be denied due to lack of documentation.Other Important Considerations
• All signatures on evaluations/UPOCs/therapy orders must be signed and dated by both the therapist and physician. If there is no date, timeliness is called into question and the claim is denied.
• All documentation must be legible.
• All goals, including long-term goals, must be written in the traditional format including timeframes and measurable outcomes.
• Signature logs must be kept up-to-date and available to turn in with any documentation requests.
• Nursing documentation of a recent significant decline must be present for long-term patients (Part B’s).