Page 206 - Medicare Benefit Policy Manual

timed code, regardless of whether or not it is billed, because the unbilled timed services
may impact the billing; and

• Total timed code treatment minutes and total treatment time in minutes. Total
treatment time includes the minutes for timed code treatment and untimed code
treatment. Total treatment time does not include time for services that are not billable
(e.g., rest periods). For Medicare purposes, it is not required that unbilled services that
are not part of the total treatment minutes be recorded, although they may be included
voluntarily to provide an accurate description of the treatment, show consistency with the
plan, or comply with state or local policies. The amount of time for each specific
intervention/modality provided to the patient may also be recorded voluntarily, but
contractors shall not require it, as it is indicated in the billing. The billing and the total
timed code treatment minutes must be consistent. See Pub. 100-04, chapter 5, section
20.2 for description of billing timed codes; and

• Signature and professional identification of the qualified professional who
furnished or supervised the services and a list of each person who contributed to that
treatment (i.e., the signature of Kathleen Smith, PTA, with notation of phone consultation
with Judy Jones, PT, supervisor, when permitted by state and local law). The signature
and identification of the supervisor need not be on each treatment note, unless the
supervisor actively participated in the treatment. Since a clinician must be identified on
the plan of care and the progress report, the name and professional identification of the
supervisor responsible for the treatment is assumed to be the clinician who wrote the plan
or report. When the treatment is supervised without active participation by the
supervisor, the supervisor is not required to cosign the treatment note written by a
qualified professional. When the responsible supervisor is absent, the presence of a
similarly qualified supervisor on the clinic roster for that day is sufficient documentation
and it is not required that the substitute supervisor sign or be identified in the
documentation.

If a treatment is added or changed under the direction of a clinician during the treatment
days between the progress reports, the change must be recorded and justified on the
medical record, either in the treatment note or the progress report, as determined by the
policies of the provider/supplier. New exercises added or changes made to the exercise
program help justify that the services are skilled. For example: The original plan was for
therapeutic activities, gait training and neuromuscular re-education. “On Feb. 1 clinician
added electrical stim. to address shoulder pain.”

Documentation of each treatment may also include the following optional elements to be
mentioned only if the qualified professional recording the note determines they are
appropriate and relevant. If these are not recorded daily, any relevant information should
be included in the progress report.

• Patient self-report;

• Adverse reaction to intervention;