Page 201 - Medicare Benefit Policy Manual

or other staff. The clinical judgment demonstrated in frequent reports may help justify
that the skills of a therapist are being applied, and that services are medically necessary.

Absences. Holidays, sick days or other patient absences may fall within the progress
report period. Days on which a patient does not encounter qualified professional or
qualified personnel for treatment, evaluation or re-evaluation do not count as treatment
days. However, absences do not affect the requirement for a progress report at least once
during each progress report period. If the patient is absent unexpectedly at the end of the
reporting period, when the clinician has not yet provided the required active participation
during that reporting period, a progress report is still required, but without the clinician’s
active participation in treatment, the requirements of the progress report period are
incomplete.

Delayed Reports. If the clinician has not written a progress report before the end of the
progress reporting period, it shall be written within 7 calendar days after the end of the
reporting period. If the clinician did not participate actively in treatment during the
progress report period, documentation of the delayed active participation shall be entered
in the treatment note as soon as possible. The treatment note shall explain the reason for
the clinician’s missed active participation. Also, the treatment note shall document the
clinician’s guidance to the assistant or qualified personnel to justify that the skills of a
therapist were required during the reporting period. It is not necessary to include in this
treatment note any information already recorded in prior treatment notes or progress
reports.

The contractor shall make a clinical judgment whether continued treatment by assistants
or qualified personnel is reasonable and necessary when the clinician has not actively
participated in treatment for longer than one reporting period. Judgment shall be based
on the individual case and documentation of the application of the clinician’s skills to
guide the assistant or qualified personnel during and after the reporting period.

Early Reports. Often, progress reports are written weekly, or even daily, at the discretion
of the clinician. Clinicians are encouraged, but not required to write progress reports
more frequently than the minimum required in order to allow anyone who reviews the
records to easily determine that the services provided are appropriate, covered and
payable.

Elements of progress reports may be written in the treatment notes if the
provider/supplier or clinician prefers. If each element required in a progress report is
included in the treatment notes at least once during the progress report period, then a
separate progress report is not required. Also, elements of the progress report may be
incorporated into a revised plan of care when one is indicated. Although the progress
report written by a therapist does not require a physician/NPP signature when written as a
stand-alone document, the revised plan of care accompanied by the progress report shall
be re-certified by a physician/NPP. See section 220.1.2C, Changes to the Therapy Plan,
for guidance on when a revised plan requires certification.