Page 193 - Medicare Benefit Policy Manual

• Evaluation and Plan of Care (may be one or two documents). Include the initial
evaluation and any re-evaluations relevant to the episode being reviewed;

• Certification (physician/NPP approval of the plan) and recertifications when
records are requested after the certification/recertification is due. See definitions in
section 220 and certification policy in section 220.1.3 of this chapter. Certification (and
recertification of the plan when applicable) are required for payment and must be
submitted when records are requested after the certification or recertification is due.

• Progress Reports (including Discharge Notes, if applicable) when records are
requested after the reports are due. (See definitions in section 220 and descriptions in
220.3 D);

• Treatment notes for each treatment day (may also serve as progress reports when
required information is included in the notes);

• A separate justification statement may be included either as a separate document
or within the other documents if the provider/supplier wishes to assure the contractor
understands their reasoning for services that are more extensive than is typical for the
condition treated. A separate statement is not required if the record justifies treatment
without further explanation.

Limits on Requirements. Contractors shall not require more specific documentation
unless other Medicare manual policies require it. Contractors may request further
information to be included in these documents concerning specific cases under review
when that information is relevant, but not submitted with records.

Dictated Documentation. For Medicare purposes, dictated therapy documentation is
considered completed on the day it was dictated. The qualified professional may edit and
electronically sign the documentation at a later date.

Dates for Documentation. The date the documentation was made is important only to
establish the date of the initial plan of care because therapy cannot begin until the plan is
established unless treatment is performed or supervised by the same clinician who
establishes the plan. However, contractors may require that treatment notes and progress
reports be entered into the record within 1 week of the last date to which the progress
report or treatment note refers. For example, if treatment began on the first of the month
at a frequency of twice a week, a progress report would be required at the end of the
month. Contractors may require that the progress report that describes that month of
treatment be dated not more than 1 week after the end of the month described in the
report.

Document Information to Meet Requirements. In preparing records, clinicians must be
familiar with the requirements for covered and payable outpatient therapy services. For
example, the records should justify: