Wednesday, June 17, 2015

CMS and Medicare MACs Offer Tips on Reducing Part B Therapy Documentation Errors

Dan Ciolek

According to the Comprehensive Error Rate Testing (CERT) Part A and Part B (A/B) and Durable Medical Equipment Medicare Administrative Contractor (MAC) Outreach & Education Task Force, common and often widespread documentation errors for outpatient rehabilitation therapy services contribute to Medicare’s national payment error rate, as measured by the 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 national coverage policy and local coverage determinations.

Additional widespread issues that result in “insufficient” documentation errors include:
  • Missing or illegible signature on the plan of care;
  • Missing or illegible signature for physician’s certification; and
  • Missing legible signature and required treatment minutes in narrative or on flow sheet.
Earlier this week the Centers For Medicare and Medicaid Services (CMS) Medicare Learning Network (MLN) published a fact sheet titled Complying With Medical Record Documentation Requests. The fact sheet was developed by MLN in conjunction with the CERT A/B MAC Outreach & Education Task Force to provide nationally-consistent education. Among the services discussed on the fact sheet were the requirements for properly documenting outpatient therapy services paid under Medicare Part B. The fact sheet includes references and links to the applicable outpatient therapy documentation requirements.

In addition to the MLN fact sheet, all 8 MACs issued a fact sheet on their respective web sites titled Task Force Scenario: Documenting Therapy and Rehabilitation Services which can be located at: Cahaba Government Benefit Administrators, CGS Administrators, National Government Services, Noridian Healthcare Solutions, Novitas Solutions, Palmetto GBA, or Wisconsin Physicians Service Corporation (Note: some of these links go directly to the document, others require website search).

In the MAC website fact sheets, the CERT A/B MAC Outreach & Education Task Force recommends providers carefully review the national and local outpatient therapy documentation requirements referenced, as well as apply the following tips for ensuring complete and accurate medical records.
  • 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.

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