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November 15, 2013

Physical Therapy and Rehabilitation Services: Results of Medical Reviews

CGS is conducting an ongoing prepayment review of physical therapy services submitted by provider specialties other than:

  • Physical Therapists
  • Physicians specializing in Rehabilitation Medicine

This prepayment review involves reviewing documentation to support the criteria for coverage of therapy services.  Coverage criteria for physical therapy services are defined in the CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 220External PDF and in the CGS Local Coverage Determination (LCD) L31886External Website, “Outpatient Physical & Occupational Therapy Services.”

Guidelines and Reminders
Key elements of required documentation include, but are not limited to:

  • Evaluation/and certified Plan of Care (include the initial evaluation and any re-evaluations relevant to the episode being reviewed);
  • Certification (physician/NNP approval of the plan required 30 treatment days after initial treatment-or delayed certification);
  • Progress Reports (provided at least once every 10 treatment days or once during the interval, whichever is less); within the report, look for:
    • Treatment Encounter Notes (may also serve as Progress Reports when required information is included in the notes). Notes should contain, but are not limited to, the following:
    • The total timed code treatment minutes and total treatment time
    • Identification of each specific intervention/modality provided and billed, for both timed and untimed codes
  • The signature and professional credentials of the qualified professional who furnished or supervised treatment; and
  • A list of personnel who contributed to treatment during that encounter.

Documentation Problem Areas
Based on our findings to date, we have identified the need for ongoing education.   Therefore, the prepayment review will continue until further notice.

The results of these reviews identified the following problems in documentation submitted for review:

  1. Records submitted for review included either no treatment plan or incomplete plan of care. The incomplete plan did not contain information concerning the amount, frequency, or duration of the therapy, and/or physician certification.

    Specific coverage requirements for physical therapy are in section 1861(p) of the Social Security ActExternal Website (SSA), which specifies that:
    • The services must be furnished under a plan of care. The plan of care indicates the type, amount, frequency, and duration of the services.
    • The plan of care (POC) must be recertified periodically by a physician.
    • The POC should be consistent with the related evaluation of the patient and the stated goals should be measurable and pertain to the functional impairments documented in the records.
  2. The submitted documentation for patients that received continued care over an extended period of time did not include a signed and dated recertification to support the necessity for continued therapy.

    The plan of care must include the diagnosis and anticipated goals of the therapy and that a physician must recertify every 30 days.
    • Reference: CGS LCD L31886External Website, “Outpatient Physical & Occupational Therapy Services”
    • Code of Federal Regulations: 42 CFR 410.60External Website and 410.61External Website
  3. The documentation submitted for review did not support physical therapy was performed on the date of service billed and/or documentation submitted indicates the service performed was not the billing Physician/NPP.

    All services should be documented in the patient record and available for review if requested by the Medicare contractor.  Section 1833(e)External Website of the SSA requires that providers furnish “such information as may be necessary in order to determine the amounts due” to receive Medicare payment. 
  4. Based on the medical record documentation provided, we could not confirm that physicians directly supervised the provision of the service.      

    Documentation received did not clearly identify who performed the therapy services; therefore reviewers are unable to determine the skill level of the staff that rendered physical therapy. 
    • A physical therapist must supervise Physical Therapy Assistants (PTAs) and Occupational Therapy Assistants (OTAs). 
    • The services of Physical Therapy Assistants (PTAs) and Occupational Therapy Assistants (OTAs) are submitted by the supervising physician and may not be submitted incident to a physician’s/NPP’s service.
      • If a Physical Therapist (PT) and PTA (or an Occupational Therapist (OT) and OTA) are both employed in a physician’s office, the services of the PTA, when directly supervised by the PT, may be billed by the physician group as PT or OT services using the PTAN of the enrolled PT (or OT).
      • If the PT or OT is not enrolled, Medicare will not pay for the services of a PTA or OTA billed incident to the physician’s service, because they do not meet the qualification standards.
    • Direct supervision (in the office suite) by a physician/NPP is required for therapists and qualified auxiliary personnel when therapy services are provided incident to the services of a physician/NPP.
    • Reference: CMS Medicare Benefit Policy Manual (Pub. 100-02), chapter 15, section 230.1.CExternal PDF
  5. Documentation submitted was illegible and/or inadequate to support medical necessity for the therapy services. 

    Medical record documentation is required for every treatment day and every therapy service to support the codes and units submitted on the claim.
    • All entries must be legible to another reader to a degree that a meaningful review can be conducted. Illegible notes will not be used in determining medical necessity of a claim.
    • Medical reviewers found that there were no objective bases for care, no identified outcomes, and/or no change in the patients’ conditions to justify ongoing therapy.
    • Timed codes were submitted without any indication to the time for the modalities.
    • The documentation submitted did not support that the modalities under review were the most effective treatments, or documentation did not meet the requirements for covered therapy as indicated in LCD L31886External Website.

Denials for Lack of Signatures:

  • Guidelines regarding signature requirements are located in the CMS Medicare Program Integrity Manual (Pub. 100-8), chapter 3, section 3.3.2.4, “Signature RequirementsExternal PDF.”  Information is also available in CMS MLN Matters article MM6698External PDF, “Signature Requirements for Medical Review Purposes.”
  • All services ordered or rendered to Medicare beneficiaries must be signed. While orders for diagnostic tests do not have to be signed, either the order must have a signature or the intent to order the specific test must be clearly documented in the medical record, and that must be signed. One or the other must be signed.
  • You should not add a late signature to the medical record but instead make use of the signature authentication process. Guidance on this signature attestation process is available in CMS MLN Matters article MM6698External PDF, “Signature Requirements for Medical Review Purposes.”  A sample attestation statementPDFis available on the CGS website.

Additional References:


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