Tips for Proper Documentation / Notation

In the wake of the recent stricter policies with regards to documentation and reimbursement I had a conversation with a woman who works to approve or more often deny our visits through Optumhealth. She was very helpful and gave me additional resources to assist in this ever-changing challenge we face. Below is a summary of our conversation along with a synopsis of the online material put together by Brad Epstein MPT.

Conversation with OptumHealth:
Necessities for each note
1. Pain – should be decreasing
2. Functional Limitations – should be showing progress and be specific i.e. standing > 20min
3. ROM – accurately take each visit / can not right “unchanged”
4. Strength – 80% or 4/5 can be rules for discharge (not mentioned during this conversation) however appears to be true
5. Therex – either have to give reps x sets x weights or show a progression of exercise i.e. clams to crab walk

A proper Treatment section may look like:
Manual:
STM -
MFR -
Jmobes -
Therex:
Neuro:

In general the company wants to know what is “skilled” about your tx session that day and why the patient showed more benefit from coming to PT vs going to see a personal trainer and a massage therapist. It is a challenge but our goal is to show where our critical thinking is a benefit to our patient and convey that with proper documentation

Here is the info from the website https://www.myoptumhealthphysicalhealth.com summarized by Brad Epstein MPT

OptimumHealth Reimbursement Policy

PT Eval Policy

· Will allow up to one evaluation unit 97001, per member, per episode of care if:

o Documented new occurrence or documented separate and distinct condition

o Documented new surgical procedure, related to a previously treated/concurrently treated condition

· An episode may include treatment related to multiple conditions

· A documented flare-up or exacerbation does not usually require a new eval but may require a re-eval

· Definitions:

o New Patient: one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years

o Episode of Care: Period of time, in calendar days, from the first day patient is under care for the current condition(s) until the last date of service for that plan of care. During the episode, the member may be treated for more than one condition; including conditions with an onset after the episode has begun.

PT Re-Evaluation Policy

· Will allow re-eval unit 97002 if and are at a max frequency of (1) every 2-4 weeks:

o Documented significant change in functional ability, impairment status or disability status.

o Documented interpretation of the current findings and assessment of continued treatment needs

o Modification in the current treatment plan and a revision of the original goals based on current findings.

o The re-eval is not a routine, recurring occurrence

o Clinical record supports the need for further tests and measurements

Documentation Requirements for Timed Therapeutic Procedures

· Therapeutic Procedures Defined (97110-97140):

o A manner of effecting change through the application of clinical skills and/or services that attempt to improve function

o Physician or therapist required to have direct (one-on-one) patient contact

o Therapeutic procedure, one or more areas, each 15 minutes

· Documentation Guidelines

o Must include both of the following:

§ Substantiation that the skilled services of a licensed therapy provider or physician were required

§ Substantiation that services met the one-on-one timed-based requirement

o Skilled Intervention

§ Documentation to support skilled intervention is required

· Document type and level of skilled assistance given to patient, clinical decision making or problem solving, and continued analysis of patient progress.

· Provide observation regarding responses before, during, and after an intervention as well as the patient’s specific response to the intervention

§ Services related to activities for the general good and welfare of patients do not constitute skilled physical medicine and rehabilitation services

§ Services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a licensed therapy provider

§ Patient’s diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled

Proper Timed Intervention Documentation

· Time reported should reflect direct one-on-one contact time with the patient.

· A licensed therapy provider can not be one-on-one with more than one patient at any given time.

· Pre, intra, and post-delivery face to face time with the patient are counted in determining the total treatment service time.

· If any 15 minute timed service is performed for 7 minutes or less on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total of the two is 8 minutes or greater, then bill one unit for the service performed for the most minutes.

· Units Number of Minutes

o 1 unit: ≥ 8 minutes through 22 minutes

o 2 units: ≥ 23 minutes through 37 minutes

o 3 units: ≥ 38 minutes through 52 minutes

o 4 units: ≥ 53 minutes through 67 minutes

o 5 units: ≥ 68 minutes through 82 minutes

o 6 units: ≥ 83 minutes through 97 minutes

o 7 units: ≥ 98 minutes through 112 minutes

o 8 units: ≥ 113 minutes through 127 minutes