1. Schaum, Kathleen D. MS

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Over the past 2 months, we have reviewed compliance tips to prevent claim denials for durable medical equipment and supplies that are needed by patients with chronic wounds. This month, we are reviewing how physicians and qualified healthcare professionals (QHPs) should properly order, certify, and recertify postacute care in a variety of settings.


Ordering Hospital Outpatient Services

In 2017, the estimated improper payment amount for outpatient services was $1.91 billion. Therefore, physicians and QHPs should take heed that the following documentation is required for hospital outpatient services to be covered by Medicare:


* Documentation that supports medical necessity of the outpatient service (eg, physician's office visit or progress note, etc)


* A signed and dated physician's order for each outpatient service, product, and procedure


* Documentation showing that each service, product, and procedure was rendered


* The ordering practitioner must authenticate the services that are provided or ordered


* Signatures may be handwritten or electronic



- Signatures may not be stamped unless the practitioner can provide proof to a Medicare Administrative Contractor of a disability that renders him/her unable to sign.


- Signatures must be legible and must follow the instructions in the Medicare Learning Network fact sheet.1



Certifying Plan of Care for Physical Therapy Services

Although there is no Medicare requirement for a physical therapy order, a physician order documented in the medical record provides evidence that the patient both needs therapy services and is under the care of a physician. Physical therapy certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care, no further certification is required. Payment is dependent on the certification of the plan of care (rather than the order), but the use of an order is prudent to determine that a physician is involved and available to certify the plan of care.


Establishing the plan of care is not the same as certifying the plan of care. The plan of care (written or dictated) must be established before outpatient physical therapy treatment is begun by either


* a physician/QHP: consultation with the treating physical therapist is recommended. NOTE: Only a physician may establish a plan of care in a comprehensive outpatient rehabilitation facility, or


* the physical therapist who will provide the services.



The signature and professional identity of the person who established the plan of care and the date it was established must be recorded with the plan of care.


The physical therapy plan of care may be entered into the patient's physical therapy record either (1) by the person who established the plan or (2) by the provider's or supplier's staff when they make a written record of that person's oral orders before treatment is begun. The plan of care shall contain, at minimum, the following information:


* diagnoses,


* long-term treatment goals, and


* the type, amount, duration, and frequency of therapy services.



Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan. It is not appropriate for a physician/QHP to certify a plan of care (1) if the patient was not under the care of some physician/QHP at the time of the treatment or (2) if the patient did not need the treatment. Because delayed certification is allowed, the date that the certification is signed is important only to determine whether it is timely or delayed. The certification must relate to treatment during the interval on the physical therapy claim. For detailed information, refer to Section 220 of the Medicare Beneficiary Policy Manual Chapter 15.2


Certifying/Recertifying Eligibility for Home Health Services

In 2017, the estimated improper payment amount for home health services was $6.11 billion.3 Medicare coverage of home health services requires physician certification/recertification of the beneficiary's eligibility for the home health benefit. Missing or inadequate certifications/recertifications were the primary reasons for the improper payment amounts.


Physicians or Medicare-allowed QHPs must certify that the beneficiary:


* is confined to the home,


* is under the care of a physician and receiving services under a plan of care established and periodically reviewed by a physician,


* needs home health services, and


* has had a face-to-face encounter with a physician or an allowed QHP related to the primary reason the beneficiary requires home health services that occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home healthcare.



For detailed information, refer to Section 30 of the Medicare Beneficiary Policy Manual Chapter 7.2


Certifying/Recertifying Eligibility for Skilled Nursing Facility Services

Medicare coverage of skilled nursing facility (SNF) services requires certification/recertification of these services. The medical record must support the medical necessity of the SNF services provided. For example, required documents include, but are not limited to


* a certification that the beneficiary needs daily skilled care that can only be provided in a SNF setting,


* an authenticated plan of care, and


* the time (in minutes) for the therapy service provided.



The documentation must also show that the services are appropriate in terms of duration and quality and promote the documented therapeutic goals.


The beneficiary's goals must be routinely assessed and documented to provide a sufficient basis for determining Medicare coverage. Therefore, the resident's medical record must document as appropriate


* the history and physical examination pertinent to the resident's care,


* the skilled services provided,


* the resident's response to the skilled services provided during the current visit,


* the plan for future care based on the rationale of prior results,


* a detailed rationale that explains the need for the skilled service,


* the complexity of the service to be performed, and


* any other pertinent characteristics of the resident.



For detailed information, refer to Chapter 8 of the Medicare Beneficiary Policy Manual.2


Establishing Medical Necessity for Admission to an Inpatient Rehabilitation Facility

The inpatient rehabilitation facility (IRF) benefit is for a beneficiary who, due to the complexity of their nursing, medical management, and rehabilitation needs, requires and can be reasonably expected to benefit from an inpatient stay and an interdisciplinary team approach to rehabilitation care. Physicians must sufficiently document and demonstrate that a beneficiary's admission to an IRF is reasonable and necessary, and at the time of admission, the beneficiary


* requires the active and ongoing therapeutic intervention of multiple therapy disciplines, one of which must be physical or occupational therapy.


* generally, requires an intensive rehabilitation therapy program of at least 3 hours of therapy per day at least 5 days per week. The standard of care for IRF patients is individualized (ie, one-on-one) therapy. Group and concurrent therapy can be used on a limited basis within the current industry standards noted above. In those instances when group therapy better meets the patient's needs on a limited basis, the situation/rationale that justifies group therapy should be specified in the patient's medical record at the IRF.


* is sufficiently stable and can reasonably be expected to actively participate in and benefit from an intensive rehabilitation therapy program. The patient can only be expected to benefit significantly from the program if the patient's condition and functional status are such that the patient can reasonably be expected to make measurable improvement (that will be of practical value to improve the patient's functional capacity or adaptation to impairments) because of the rehabilitation treatment and if such improvement can be expected within a prescribed period.


* requires physician supervision by a rehabilitation physician, defined as a licensed physician with specialized training and experience in inpatient rehabilitation. This means that the rehabilitation physician must conduct face-to-face visits with the patient at least 3 days per week throughout the patient's stay in the IRF to assess the patient both medically and functionally, and modify the course of treatment as needed to maximize the patient's capacity to benefit from the rehabilitation process.


* requires an intensive and coordinated interdisciplinary approach to providing rehabilitation.



For detailed information, refer to Chapter 1, Section 110 of the Medicare Benefit Policy Manual.2




2. Centers for Medicare & Medicaid Services. MLN Fact Sheet: Complying with Medicare Signature Requirements. May 2018. Last accessed July 31, 2018. [Context Link]


3. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual. Last accessed July 31, 2018. [Context Link]


1. Centers for Medicare & Medicaid Services. MLN Fact Sheet: Provider Compliance Tips for Home Health Services (Part A Non DRG). February 2018. Last accessed June 12, 2018. [Context Link]