Outpatient Rehabilitation Therapy Documentation Requirements

Outpatient Rehabilitation Therapy

Outpatient rehabilitation therapy comprises physical therapy, occupational therapy, speech and language therapy services. Rehabilitation helps people get back, maintain, or improve abilities needed for daily living. Physical therapists, for instance, identify, diagnose, and treat mobility issues and help people of all ages restore their functional abilities, and avoid the need for surgery. Rehabilitation therapy can reduce the symptoms of many chronic diseases and conditions, and help people get their abilities back after surgery or injuries and trauma. While providing interventions to meet the specific needs of each patient, therapists need to maintain proper documentation to justify services and ensure appropriate reimbursement from Medicare and private insurance plans. Since many providers find it challenging to document effectively while providing care, medical transcription outsourcing has emerged as a reliable option for consistently and accurately reporting rehab services.

Importance of Effective Documentation for Therapy Services

 Consistent and accurate information in the medical record and the documentation accompanying claims is critical to:

  • Show that the therapy services were medically necessary.
  • Justify the appropriate type of services, frequency, intensity, and duration for the individual needs of the patient.
  • Ensure compliance with the exceptions process – there is a targeted medical review threshold for occupational therapy and for speech-language pathology and physical therapy combined. The documentation should support the provision of services above the cap.
  • comply with all legal/regulatory requirements applicable to payer requirements for claims
  • get paid for the covered therapy services

 Outpatient Rehabilitation Therapy – What Documentation Should Include

Documentation should:

  • Establish the need for therapy services.
  • Establish the factors that influence the patient’s condition, especially the factors that influence the clinician’s decision to provide more services than are typical for the individual’s condition.
  • Provide objective measurements to establish that that the patient is making progress toward goals. As plains (no progress) or valleys (regression) can happen during treatment, CMS recommends that the documentation notes the reasons for lack of progress and the justification for continued treatment if treatment continues after plains and valleys.

Types of Documentation for Therapy Services

  • Written Plan of Care (POC): Therapy services should be specifically associated with a written treatment plan or POC, including an evaluation. It is necessary to establish the POC before the therapy begins. In a Comprehensive Outpatient Rehabilitation Facility (CORF), only the physician can establish the POC. The POC should include the following information:
    • Diagnoses
    • Long term treatment goals; and
    • Type, (PT, OT or SLP) amount, duration, and frequency of therapy services)
    • The signature and professional identity of the person who established the POC and the date
    • The physician’s or NPP’s written or verbal approval
    • Any significant long-term goals

The evaluation should include a diagnosis and description of the specific problem(s) to be evaluated and/or treated. The medical record documentation should identify objective, measurable patient physical function including functional assessment and measurable progress towards identified goals for functioning in the home environment at the completion of the therapy episode of care. The referral/order of a physician/NPP is essential to show that the evaluation is needed and the patient is under the care of a physician.

If it is difficult to document the POC while providing care, PTs can develop a dictated POC and get it converted into text using a physical therapy transcription service.

  • Progress Reports: Progress notes need to establish the medical necessity of the therapy services. ASHA states that:
    • The clinician must complete a progress report at least once every 10 treatment days or at least once during each certification interval, whichever is less.
    • The first reporting period begins on the first day of the episode of treatment regardless of the services provided – evaluation, re-evaluation, or treatment.
    • The progress report should contain an assessment of improvement or lack of it for each goal; plans for continuing treatment, additional evaluation results, and/or treatment plan modifications; changes to long- or short-term goals, discharge, or an updated plan of care sent to the physician/NPP for approval of continuation of treatment.
    • The notes could include objective evidence (patient assessment instruments, tests, outcome measurement tools) that the patient’s condition has the potential to improve in a reasonable and generally predictable period of time or is improving in response to therapy. Though not required, the use of these tools will support the need for the therapy.
  • Treatment Notes: Treatment notes should provide a record of all encounters and skilled intervention. Every therapy service provided on each treatment day should be documented and must include the following:
    • The name of the treatment, intervention of activity provided in the encounter note.
    • Total treatment time.
    • Any changes in treatment with justification for the same.
    • Upgrades to the patient’s activity that show skilled treatment. Including objective measurement to support this can be helpful.
    • If there is no improvement, information on any setbacks, illness, new condition, or social circumstances that are hindering progress and reasons why attaining progress is still possible.
  • Discharge Note: The discharge note written by the clinician should include all treatment provided since the last progress report to the date of discharge. It should indicate that the notes were reviewed by therapist and that the therapist agrees to the discharge.

Physical and occupational therapy services provided in an outpatient setting can take place in the office, hospital, home, and other settings. To show that the standards of care were met and receive reimbursement for their services, providers should submit error-free claims with comprehensive and appropriate documentation to meet payer rules and federal policies. Partnering with a medical transcription outsourcing company can ensure clear and complete outpatient therapy records to:

  • Provide quality patient care
  • Ensure continuity of care
  • Correct coding and billing
  • Avoid malpractice
  • Maintain complete HIPAA-compliance

US based medical transcription companies provide timely and focused EHR documentation solutions for all specialties including physical therapy, occupational therapy, and more.