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  • Medicare Provides Tips on Reducing Errors Around Insufficient Documentation

    According to Medicare administrative contractors (MACs), physical therapy procedures are among the "more common" procedures that get denied due to insufficient documentation. It's a pattern they're hoping to change through additional information aimed in part at physical therapists (PTs).

    Earlier this month, a task force made up of all 8 MACs issued a fact sheet and a "task force scenario" (.pdf) that highlights, among other things, what PTs should be aware of when it comes to developing a plan of care. According to the fact sheet, the main problem encountered with physical therapy services is insufficient signatures and dates on plans of care. The fact sheet provides details and links to the specific requirements.

    A second document, titled "Task Force Scenario: Documenting therapy and rehabilitative services," is available at all 8 MAC websites, and goes into even more detail on how to reduce the risk of errors attributed to insufficient documentation. Among the tips provided:

    • Ensure the medical records provide proof the service was certified and rendered.
    • Ensure the medical records provide justification for medical necessity and need for skilled services.
    • Create a complete plan of care that includes signatures, professional designation, and date.
    • Document when the plan of care is modified and why, including an explanation of why previous goals were not or could not be met.
    • Confirm that the plan of care is certified appropriately with the physician or nonphysician practitioner.
    • Clearly document, in minutes, the total time spent on timed-code treatment only and the total treatment time in the patient's record.

    For the complete guidance document, visit the website of the applicable MAC (direct links to the scenario document have been provided where possible): Cahaba Government Benefit Administrators, CGS Administrators, National Government Services, Noridian Healthcare Solutions, Novitas Solutions, Palmetto GBA, or Wisconsin Physicians Service Corporation.

    Learn more about how to avoid Medicare documentation errors: the APTA Center for Integrity in Practice website offers a webpage dedicated to documentation.

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