Palmetto GBA: Home Health Request Therapy Documentation Requirements

Home health providers should be aware that Palmetto GBA has identified deficiencies in therapy documentation. Medicare regulations state, in part, ‘To ensure therapy services are effective, at defined points during a course of treatment, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must perform the ordered therapy service. During this visit, the therapist must assess the patient using a method which allows for objective measurement of function and successive comparison of measurements. The therapist must document the measurement results in the clinical record.’

In reviewing the documentation submitted through the Additional Documentation Request (ADR) process, Palmetto GBA has noted the following deficiencies:

  1. The therapists are not writing their credentials on the evaluation or re-evaluation form. The reviewer is not able to determine if the evaluation or re-evaluation is completed by a therapist or therapy assistant.
    • Therapists, not assistants, are required to conduct the assessments at specific intervals. In order for Palmetto GBA to ensure that Medicare regulations are being met, the documentation must clearly provide the therapist and the appropriate credentials.
  2. Illegible signature of the therapist
    • Medicare signature requirements mandate that if the signature of the person signing the document is not legible, identifying information (such as a signature log, attestation statement, typed name under the signature, etc.) must also be included in the documentation
  3. Illegible credential
    • When the credentials are either illegible or missing, Palmetto GBA is unable to verify that the respective therapist actually conducted the evaluation/re-evaluation
  4. Measurement results are not documented in the medical record
    • Medicare guidelines state, ‘…the therapist must assess the patient using a method which allows for objective measurement of function and successive comparison of measurements.’ Thus, when the documentation does not contain clearly identified measurements in the results, payment cannot be allowed on the claim for those services.
  5. Reassessments are not being completed within the required timeframe
    • Medicare regulations require that reassessments must be done at least once every 30 days and prior to the 14th and 20th therapy visit
  6. Providers are not submitting the required reassessment(s) when responding to the ADR requests
    • When responding to an ADR, it is important that providers include all documentation that applies to the services billed. This may include documentation that contains dates that are outside the dates of service billed on the claim. When therapy services are provided, the documentation submitted in response to an ADR should also include all therapy documentation.

Reference: CMS IOM, Publication 100-02, Chapter 7, Section 40.2.1

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