Page 204 - Medicare Benefit Policy Manual

care may not be changed during the episode of care to which the plan refers. A clinician,
an assistant on the order of a therapist or qualified personnel on the order of a
physician/NPP shall add new goals with new identifiers or letters. Omit reference to a
goal after a clinician has reported it to be met, and that clinician’s signature verifies the
change.

Content of Clinician (Therapist, Physician/NPP) Progress Reports. In addition to the
requirements above for notes written by assistants, the progress report of a clinician shall
also include:

• Assessment of improvement, extent of progress (or lack thereof) toward each
goal;

• Plans for continuing treatment, reference to additional evaluation results, and/or
treatment plan revisions should be documented in the clinician’s progress report; and

• Changes to long or short term goals, discharge or an updated plan of care that is
sent to the physician/NPP for certification of the next interval of treatment.

• Functional documentation is required as part of the progress report at the end of
each progress reporting period. It is also required at the time of discharge on the
discharge note or summary, as applicable. The clinician documents, on the applicable
dates of service, the specific nonpayable G-codes and severity modifiers used in the
required reporting of the patient’s functional limitation(s) on the claim for services,
including how the modifier selection was made. See subsection C of 220.4 below for
details relevant to documentation requirements.

A re-evaluation should not be required before every progress report routinely, but may be
appropriate when assessment suggests changes not anticipated in the original plan of
care.

Care must be taken to assure that documentation justifies the necessity of the services
provided during the reporting period, particularly when reports are written at the
minimum frequency. Justification for treatment must include, for example, objective
evidence or a clinically supportable statement of expectation that:

• In the case of rehabilitative therapy, the patient’s condition has the potential to
improve or is improving in response to therapy, maximum improvement is yet to
be attained; and there is an expectation that the anticipated improvement is
attainable in a reasonable and generally predictable period of time.

• In the case of maintenance therapy, treatment by the therapist is necessary to
maintain, prevent or slow further deterioration of the patient’s functional status
and the services cannot be safely carried out by the beneficiary him or herself, a
family member, another caregiver or unskilled personnel.