Page 205 - Medicare Benefit Policy Manual

Objective evidence consists of standardized patient assessment instruments, outcome
measurements tools or measurable assessments of functional outcome. Use of objective
measures at the beginning of treatment, during and/or after treatment is recommended to
quantify progress and support justifications for continued treatment. Such tools are not
required, but their use will enhance the justification for needed therapy.

Example: The Plan states diagnosis is 787.2- Dysphagia secondary to other late effects
of CVA. Patient is on a restricted diet and wants to drink thick liquids. Therapy is
planned 3X week, 45 minute sessions for 6 weeks. Long term goal is to consume a
mechanical soft diet with thin liquids without complications such as aspiration
pneumonia. Short Term Goal 1: Patient will improve rate of laryngeal elevation/timing
of closure by using the super-supraglottic swallow on saliva swallows without cues on
90% of trials. Goal 2: Patient will compensate for reduced laryngeal elevation by
controlling bolus size to ½ teaspoon without cues 100%. The progress report for 1/3/06
to 1/29/06 states: 1. Improved to 80% of trials; 2. Achieved. Comments: Highly
motivated; spouse assists with practicing, compliant with current restrictions. New Goal:
“5. Patient will implement above strategies to swallow a sip of water without coughing
for 5 consecutive trials. Mary Johns, CCC-SLP, 1/29/06.” Note the provider is billing
92526 three times a week, consistent with the plan; progress is documented; skilled
treatment is documented.

E. Treatment Note

The purpose of these notes is simply to create a record of all treatments and skilled
interventions that are provided and to record the time of the services in order to justify the
use of billing codes on the claim. Documentation is required for every treatment day, and
every therapy service. The format shall not be dictated by contractors and may vary
depending on the practice of the responsible clinician and/or the clinical setting.

The treatment note is not required to document the medical necessity or appropriateness
of the ongoing therapy services. Descriptions of skilled interventions should be included
in the plan or the progress reports and are allowed, but not required daily. Non-skilled
interventions need not be recorded in the treatment notes as they are not billable.
However, notation of non-skilled treatment or report of activities performed by the
patient or non-skilled staff may be reported voluntarily as additional information if they
are relevant and not billed. Specifics such as number of repetitions of an exercise and
other details included in the plan of care need not be repeated in the treatment notes
unless they are changed from the plan.

Documentation of each treatment shall include the following required elements:

• Date of treatment; and

• Identification of each specific intervention/modality provided and billed, for
both timed and untimed codes, in language that can be compared with the billing on the
claim to verify correct coding. Record each service provided that is represented by a