Documentation Clinical Notes - Copy (2)

04/15/2023 Dr. Charles Curtis MS, PT,DPT, MDT 1

CLINICAL NOTESRehabilitation Clinical

Documentation


Clinical Notes

The goals aligned with the patients plan of care are based on the patient centered functional goals.


Clinical Notes

Long Term Goal: The clinical goals are expected to be

achievable and realistic within the designated time frame and the treatments listed (referred to as the treatment plan) are necessary to achieve these goals within the designated time frame.


Clinical Notes

The functional goals were created based on the reported patient’s prior level of function as compared to the assessed current level of function.

Goals are Identified by: Valid and Reliable functional test Objective measures Co-morbidities Therapist judgment


Validity Defined

Test is measuring what it is intended to measure Balance Dizziness Back Pain Neck Pain Leg function Arm function


Reliability Defined

Broadly defined: One is able to rely on the test scores being

accurate and reproducible


Objective Measures

Data that are measureable Impairments

Strength Pain Range of Motion Reflexes Circumference measures

Function Functional Tests

TGUG Berg

Questionnaires Oswestry Neck Disability Index


Comorbidities

Issue that affect the outcome of treatment Age Past Medical History Family participation Cognitive Issues Access to attend PT Equipment needs


Therapist Judgment

To determine functional status or level of disability the following must be considered Prior Level of Function Severity of Procedure/Pathology/Disease Objective Impairment Finding Functional Test(s) scores and the consideration

of the minimally detectable change and cut offs

Motivation of patient and family Experience of therapist


DOCUMENTING MEDICAL NECESSITY

THRU OUTCOMES ASSESSMENT


OUTCOMES

Outcomes Assessment Collection and recording of information

relative to health processes Outcomes Management

Using information in a way that enhances patient care

(Hansen DT, Mior S, Mootz RD in Yeomans SG: The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)


The Era of Outcomes Assessment

Outcomes in clinical practice provide the mechanism by which the health care provider, the patient, the public, and the payer are able to assess the end results of care and its effect upon the health of the patient and society. (Anderson & Weinstein, 1994).


Survival

To survive, in fact to flourish, in this era of accountability health care providers must be prepared to maintain and be able to provide appropriate documentation and patient records in a clinically efficient and economical manner. (Hansen, 1994).


Health Policy

With the dawning, of the “era of accountability,” there are new social mandates directed toward health care providers and health-related facilities. Measurements of quality, satisfaction, efficacy, and effectiveness now serve as essential elements for health care decisions and matters of health policy. (Hansen DT, Mior S, Mootz RD in Yeomans SG:

The Clinical Application of Outcomes Assessment, Stamford Connecticut, Appleton & Lange, 2000)


Outcome Meanings

Health Care Customer - Meaning of Outcomes Payers-purchasers Cost containment Regulators HCP compliance Administrators Efficiency-low

utilization Clinical Researchers Proof of a premise Outcomes Experts Patient’s benefit Health Care Providers Clinical-Health

Status



Outcomes Criteria

Utility Is it useful? Reliability Is it dependable? Validity Does it do what it is

supposed to? Sensitivity Can it identify patients with

a condition? Specificity Can it identify those that do

not have the condition? Responsiveness Can it measure

differences over time?


Outcome Measures Appropriate for Clinical Use

Questionnaires General health status Pain Functional status Patient satisfaction

Physiological outcomes Utilization measures Cost measures


Outcomes Measures Appropriately Used

When outcome measures are appropriately used and integrated into an evidence-based, patient-centered model of practice, there is accountability and quality assurance.



Subjective Questionnaires

Subjective outcomes assessment information is gathered by the patient in self-administered questionnaires and scored by either the: health care provider staff members or by a computer.


Subjective Questionnaires

In spite of the definition associated with the term “subjective,” these “pen-and-paper tools” have been described as very valid and reliable – in many cases more so than many of the “objective’ tests that health care providers have relied upon for years.

(Chapman-Smith, 1992; Hansen, 1994; Mootz, 1994).


Subjective vs Objective

It must be emphasized that although the term “subjective” carries negative connotations, the reliability/validity data published regarding these methods of collecting outcomes is exceptional, typically out-performing the test-retest reliability and validity of most “objective” physical performance tests. (Chapman-Smith, 1992).


Classification of Outcome Assessment Tools

Subjective (Patient Driven)

General Health Pain Perception Condition or Disease Specific Psychometric Disability Prediction Patient Satisfaction Prior Level of function

Objective (HCP Driven)

Range of Motion Strength - Endurance Nonorganic Proprioception Cardiopulmonary Developmental Neurological Pain (VAS) Integumentary Special Test Functional Tests


Outcomes Assessment Tools

It is important to remember to utilize the same outcome assessment tool through the course of case management with each patient.


Defining Terms

Progress Note Re-assessment Re-evaluation


Clinical Notes

The progress notes allows the therapist to determine the effectiveness of the allocated plan of care and to measure the clinical findings that are compared to the clinical goals that establish indicators of progress toward addressing functional limitations and achieving functional goals.

Falls hand and hand with the Re-assessment


Clinical Notes

A re-evaluation is performed when a significant changes has taken place and there is an alteration in the plan of care.

Be careful not to over-utilize this code in your billing methodology


Clinical Notes

The functional goals are based upon a correlation of functional assessment tools, clinical findings/tests, performance based tests, objective findings and the therapist judgment call.


Nagi:Functional Levels

Impairment: Loss or abnormality of anatomical, physiological,

mental, or psychological structure or function. Organ specific

Functional Limitation Restriction of ability to perform, at the level of the

whole person, a physical action, task or activity in an efficient, typically expected, or competent manner. Person specific.

Disability: The inability to perform or a limitation in the

performance of actions, tasks, and activities usually expected in specific social roles.

(Nagi, S. Some conceptual issues in disability and rehabilitation. In : Sussman M, ed Sociology and Rehabilitation. Washington DC: American Sociology Society; 1965: 100-113)


APTA References to Proper Clinical Documentation

APTA has numerous publication that address components of clinical documentation. Below are a list of three publications that will be discussed. Guide to Physical Therapy Practice Peer Review/Utilization Review Task Force on Measurements APTA Standards of Tests and Measurements Primer on Measurement: An introductory guide to

measurement issues. (Rothstein, Echternach) WHO: International classification of functioning,

disability and health


Components of Proper Clinical Justification

Documentation

Justification

PLOF to CLOF

Impairments linked

To Function

Outcomes Measured

Patient CenterFunctional

Goals

Test: valid and

Reliable

04/15/2023

MEASUREMENT AND UTILIZATION REVIEW

Dr. Charles Curtis MS, PT,DPT, MDT31

Validity and Reliability. Concurrent and Retrospective Reviews


Physical Therapy Scope of Practice

Provide services to patients/clients who have impairments, functional limitation, disabilities or changes in physical function and health status resulting from injury, disease or other causes.

(Guide to Physical Therapy Practice 2nd Edition. pg S31)


Utilization Review

What is needed for Review The inclusion of the patient in establishing goals:

Patient centered functional goals A statement of impairment related to functional

limitation Valid Function Tests with reliable scores

A statement on any changes in health status, wellness, and fitness needs to be identified Objective noted with impairment measures

Medicare signed plan of care Physician signature

MD script for most commercial products Direct access does not require us to have a script just

communication with patient’s physician


Medical and Scientific Evidence

To set criteria for the effectiveness and efficiency of a test Peer Review articles are defined: Peer-review scientific studies published in, or

in accepted for publication by, medical journals that meet nationally recognized requirements for scientific manuscripts and that submit most of their published articles for review by experts who are not part of the editorial staff.


Summary of Section

Scope of practice is a key component to keep in mind as to what services a PT should provide.

Valid and Reliable Measure are an essential part of clinical documentation.

Scientific literature is the source of information regarding the application of tests and how to interpret the findings

Validity: is the test measuring what it claims to Reliability: is the test consistent and stable and

reproducible.

04/15/2023

INSURANCE COMPANIES AND UTILIZATION REVIEW

Dr. Charles Curtis MS, PT,DPT, MDT36

View on Documentation and Function


Utilization Review

Utilization Review Process Defined The review to determine whether health care

services that have been provided, are being provided or are proposed to be provided to a patient, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary.


Utilization Review

Concurrent Review Defined: The review preformed at the time of

treatment. Review is performed to determine medical

necessity of the treatment performed and it effect on the consequence of disease , including

impairments, functional limitations, patient centered functional goals that justify

treatment, which lead to the foundation of medically necessary.


Utilization Review

The fact that a provider and or physician (par or non par) has made a prescribed, recommended, or approved a service, supply or equipment, does not in itself, makes it medically necessary.

What is required: Justification through written documentation

utilizing measurement that are valid and reliable

These are the items that are required by a majority of Utilization review process


Summary of Documentation Requirements

What is required by parties interested in documentation? Proof that care is necessary, effective and

important to the patient. How do we do this?

At the core of proper documentation is the validity and reliability of the measurements. Linking these measurement changes, from an impairments view and the direct association to the functional limitation, of the patient.


Authors Views on Documentation


Peat, et al. (1979) Analysis of Performance

According to Peat and Campbell (1979) “…the profession (physical therapy) has been

criticized for not objectively recording events” Why:

Primary tools in the assessment of motor performance are visual tools and gross motor test.

Visual test disadvantage is the absence of quantification of specific parameters of the event

The validity of the test is placed on the therapist personal observation a particular response.


Peat (1979) Analysis of Performance

To improve our clinical documentation there must be: An emphasis on function we must be able to

analysis performance An analysis of performance is the quantification

of stipulated parameters, comparison of parameters with respect to a

normative data, comparison of the present and previous states of

results for the same set of parameters.


How to improve recording of motor performance tasks?

In the analysis of motor performance look to two components: Product or outcome

Effectiveness Efficiency

Process Biomechanical efficiency Biomechanics is the science of accelerations,

forces, and displacements acting on the human body and the injuries caused by these forces


Product or outcome

Effectiveness: The degree of success attained in the

achievement of the goal Efficiency:

Ratio of mechanical work accomplished by the total work accomplished (How much effort to how much work). Directly related to time, distance, force and accuracy.


ProcessBiomechanical efficiency

Biomechanical efficiency Skill of task.

Exhibited by patient when attempting to perform a movement

Gross measurement (ie. Gross gait pattern)


Biomechanics

The human body is subject to gravitational force and through the study of these force we can maintain or improve a humans overall quality of life.

Any injury to, or lesion in, any of the individual elements of the musculoskeletal system will change the mechanical interaction and cause degradation, instability or disability of movement.


Biomechanics

In response to these negative adaptations: proper modification, manipulation and control

of the mechanical environment can help prevent injury, correct abnormality, and speed healing and rehabilitation.

To Accomplish this, an understanding the biomechanics and

loading of each element during movement using visual assessment and or motion analysis is helpful for studying disease etiology, making decisions about treatment, and evaluating treatment effects


Peat and Campbell Summary

Proper documentation should follow the same outline as analysis of movement: Effectiveness of a functional task should be

measured by the degree of success attained by the achievement of the task or activity

Efficiency of a functional task to measure time, distance, force or energy required and accuracy of the task. (RPE example of measuring this)


Randall and McEwen (2000)Patient-Centered Functional Goals

All areas including, research, health care policy reimbursement practices and the standards of accrediting bodies all support writing patient-centered functional goals.

Reason: It promotes a patient-centered approach in

which PT actively facilitate the participation of the patient/client, family, significant other and caregivers in the plan of care.



Rational for such goals: Functional Goals are necessary to address

the fact that correction of impairment alone is not directly functional and may not necessarily lead to functional improvements or may not be meaningful to the patient.



Function: those activities identified by individual as essential to support physical, social, and psychological well being and to create a personal sense of meaningful living.

Goals: remediation of impairment and uses the term “outcomes” for minimization of functional limitation, optimization of health status, prevention of disabilities, and optimization of patient/client satisfaction.

Primary goal is to maintain and improve the quality of life of an individual—

empowering independency


Functional Goals

Defined: as the individually meaningful activities that a person cannot perform as a result of an injury, illness or congenital or acquired condition, but want to be able to accomplish as a result of physical limitation.


Steffen and Meyer (1995)

The shift in federal guidelines of cost reimbursement have alternatively benefited, bewildered and penalized the clinics.

The potential shift to a dependency of reimbursement on the evidence based practice will be required to utilize and document credible measures of outcomes.

Why? to safe guard our patients interest and to promote our own professional self interest


Steffen and Meyer (1995)

Appropriate question to identify patient centered functional goals. Determine the patients desired outcomes Rank outcomes in priority order. (Ask patient

which of their goals is the most important) Develop an understanding of patients self

care, work, and leisure activities and environment in which these activities occur (Life style, hobbies, activity levels, etc.)

Establish goals with the patient and if necessary with family that relate to desired outcomes.


Rothstein and Echternach (2001)HOAC II

Hypothesis Orientated Algorithm for Clinicians II (HOAC II) A new decision making and documentation

guide in physical therapy. It is to serve as a template for documentation

and as a conceptual model for decision making and therefore, could link documentation and practice.



Algorithm presented provide a problem solving approach to clinical decision

Divides patient problems into two categoriesPatient identified problems (PIP):Non patient identified problems

(NPIP):


Patient Identified problems

Consist of functional limitations and disabilities identified by patient, will often exist when therapist is performing initial evaluation, however these items can also be anticipated by the therapist.

Generated before examination, therefore driven by patient.


Non Patient Identified Problems

Problems that may occur (Risk Factors) or existing problems not expressed by the patient, but found

by therapist.



Testing Criteria Used to examine correctness of hypothesis related to

problems that currently exist. Informs us of the level of performance that a patient needs to achieve to eliminate a problem (impairment and functional limitation).

Predictive Criteria Measured for anticipated problems. How long

intervention for prevention should be carried out. A focus on risk factors that lead to corrective hypothesis, reduced risk factors. These are not goals because they are worth achieving only if sufficient evidence indicates that a problems might occur.



HOAC II: prevention activities are goal driven and are

planned for specified period of time, therapists can, through use of the algorithm, identify to payers the resources they will need to achieve prevention.


Hypothesis generation

With two types of problems two types of hypotheses are needed (Evidence-Based Preferred or Logic as to the need) Existing Problems Hypotheses: requires

hypotheses about the diagnosis that detail what needs to be changed to eliminate existing problems.

Anticipated Problems: Elimination of risk factors and a case as to what may happen with out intervention.


Anticipated problems

Rational for the intervention to avoid a problem is difficult. Must look to the risk factors and the removal of such. Epidemiological base Augmentative / Logic base with some type of

scientific basis Justification is critical with this type of

problem.


HOAC II Goals

Goals: To base a goal on the change in impairment is almost always inappropriate

Goals should represent meaningful accomplishments. Changes are functional


HOAC II Goals

The simplest way of checking whether a goal is appropriate Whether the payer would find therapy to be

worthwhile if this is all that is achieved Whether anyone would feel therapy was

worthwhile if this is all that was achieved Commit to a evaluation schedule,

identifiable time lines when status of patient will be checked


How to make these changes?

Provide measurement tools to clinical personnel and qualify existing documents, training and competencyMake all clinical personnel accountable to documentation requirementsQuality assurance preformed on documentation (Peer Review ¼’ly) with reports and action plans. Included in yearly review


What impact will be made by improved documentation

Improve the field of physical therapy Improve the quality of care to patients Improve efficiency and effectiveness of

care with closer monitoring Reduce denials for utilization review Add to evidence based practice data base

with published outcomes Provide data to potential clients


Points to remember

Points to Remember Document all objective data on evaluation

Compare prior level of function to current level Medicare looks at a 90-180 day as the time line.

Link all functional limitations with impairments Re-measure often to determine effectiveness Use measurements that are valid and reliable All goals should be patient centered, realistic and

functional. Good documentation leads to justification of treatments

that leads to improved quality of care to patients


Valid and Reliable Tests1) Six minute walk test (pulmonary/cardiac)

Olsson L, Swedberg K. Eur Heart J. 2005 Oct;26(20):2209. Epub 2005 Aug 16. 2) DASH (upper extremity)

Deshmukh, AV et al. Total shoulder arthroplasty: Long-term survivorship, functional outcome, and quality of life. J Shoulder Elbow Surg. 2005 Sep-Oct;14(5):471-9.

3) Oswastry (low back)Ostelo, RW, de Vet HC. Clinically important outcomes in low back pain.Best Pract Res Clin Rheumatol. 2005 Aug;19(4):593-607. Review

4) Neck index Wlodyka-Demaillle, S.The ability to change of three questionnaires for neck pain.Joint Bone Spine. 2004 Jul;71(4):317-26.

5) Lower Extremity Motor Coordination TestDesrosiers, J. et al. Validation of a new lower-extremity motor coordination test.Arch Phys Med Rehabil. 2005 May;86(5):993-8.

6) Berg balance (out patient) Paltamaa, J. et al Reliability of physical functioning measures in ambulatory subjects with MS.Physiother Res Int. 2005;10(2):93-109. PMID: 15895347

7) Tinnitte (snf, long term care)Mold, JW et al. The prevalence, predictors, and consequences of peripheral sensory neuropathy in older patients.J Am Board Fam Pract. 2004 Sep-Oct;17(5):309-18.


CMS Documentation Overview


Triangle of Review

The ICD-9 and CPT code match up CCI edits with CPT codes Documentation:

Functional Objective Test

Valid Reliable

04/15/2023 Dr. Charles Curtis MS, PT,DPT, MDT72

Medicare Triangle of Justification

ICD-9 CPT codeMatch-upMedical Necessity

CCI Edits

Functional Changes via Documentation of patients Centered Functional Goals


CMS Documentation Requirements

Documentation required to indicate objective, measurable beneficiary physical function including, e.g., Functional assessment individual item and summary

scores (and comparisons to prior assessment scores) from commercially available therapy outcomes instruments other than those listed above; or

Functional assessment scores (and comparisons to prior assessment scores) from tests and measurements validated in the professional literature that are appropriate for the condition/function being measured; or


CMS Documentation Requirements Continued

Other measurable progress towards identified goals for functioning in the home environment at the conclusion of this therapy episode of care.

Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools; and


CMS Documentation Requirements Cont

A determination that treatment is not needed, or, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.

Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools; and

A determination that treatment is not needed, or, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.


CMS Supporting Documentation

Documentation supporting medical care prior to the current episode, if any, (or document none) including, e.g., Record of discharge from a Part A qualifying inpatient,

SNF, or home health episode within 30 days of the onset of this outpatient therapy episode, or

Identification of whether beneficiary was treated for this same condition previously by the same therapy discipline (regardless of where prior services were furnished; and

Record of a previous episode of therapy treatment from the same or different therapy discipline in the past year.



Documentation required to indicate beneficiary health related to quality of life, specifically, The beneficiary’s response to the following

question of self-related health: “At the present time, would you say that your health is excellent, very good, fair, or poor?” If the beneficiary is unable to respond, indicate why; and



Documentation required to indicate beneficiary social support including, specifically, Where does the beneficiary live (or intend to live) at the

conclusion of this outpatient therapy episode? (e.g., private home, private apartment, rented room, group home, board and care apartment, assisted living, SNF), and

Who does beneficiary live with (or intend to live with) at the conclusion of this outpatient therapy episode? (e.g., lives alone, spouse/significant other, child/children, other relative, unrelated person(s), personal care attendant), and



Does the beneficiary require this outpatient therapy plan of care in order to return to a premorbid (or reside in a new) living environment, and

Does the beneficiary require this outpatient therapy plan of care in order to reduce Activities of Daily Living (ADL) or Instrumental Activities of Daily Living or (IADL) assistance to a premorbid level or to reside in a new level of living environment (document prior level of independence and current assistance needs); and



Progress Note: Timing. The minimum Progress Report Period shall be at least

once every 10 treatment days or at least once during each 30 calendar days, whichever is less.

The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, re-evaluation or treatment. Regardless of the date on which the report is actually written (and dated),

the end of the Progress Report Period is either a date chosen by the clinician, the 10th treatment day, or the 30th calendar day of the episode of treatment, whichever is shorter.

The next treatment day begins the next reporting period. The Progress Report Period requirements are complete when both the elements of the Progress Report and the clinician’s active participation in treatment have been documented.


CMS Discharge Note

The Discharge Note or Discharge Summary:

is required for each episode of outpatient treatment. In provider settings where the physician/NPP writes a discharge summary and the discharge documentation meets the requirements of the provider setting, a separate discharge note written by a therapist is not required.

The Discharge Note shall be a Progress Report written by a clinician, and shall cover the reporting period from the last Progress Report to the date of discharge.

In the case of a discharge unanticipated in the plan or previous Progress Report, the clinician may base any judgments required to write the report on the Treatment Notes and verbal reports of the assistant or qualified personnel.


Discharge Note

At the discretion of the clinician, the discharge note may include additional information; for example, it may summarize the entire episode of treatment, or justify services that may have extended beyond those usually expected for the patient’s condition.

Clinicians should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed. The record should be reviewed and organized so that the required documentation is ready for presentation to the contractor if requested.


Treatment Note

The purpose of these notes is simply to create a record of all treatments and skilled interventions and to record the time of the services in order to justify the use of billing codes on the claim.

Documentation is required for every treatment day, and every therapy service.

The Treatment Note is not required to document the medical necessity or appropriateness of the ongoing therapy services.

Descriptions of skilled interventions should be included in the plan or the Progress Reports and are allowed, but not required daily.


Treatment Note

Non-skilled interventions need not be recorded in the Treatment Notes as they are not billable.

However, notation of non-skilled treatment or report of activities performed by the patient or non-skilled staff may be reported voluntarily as additional information if they are relevant and not billed.

Specifics such as number of repetitions of an exercise and other details included in the plan of care need not be repeated in the Treatment Notes unless they are changed from the plan.


Treatment NoteIntervention

Documentation of each Treatment shall include the following required elements:

Date of treatment; and

Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding. Record each service provided that is represented by a timed code, regardless of whether or not it is billed, because the unbilled timed services may impact the billing; and


Treatment Note Time Codes

Total timed code treatment minutes and total treatment time in minutes. Total treatment time includes the minutes for timed code treatment and untimed code treatment.

Total treatment time does not include time for services that are not billable (e.g., rest periods). For Medicare purposes, it is not required that unbilled services that are not part of the total treatment minutes be recorded, although they may be included voluntarily to provide an accurate description of the treatment, show consistency with the plan, or comply with state or local policies.


Treatment Notes and Timed Codes

The amount of time for each specific intervention/modality provided to the patient may also be recorded voluntarily, but contractors shall not require it, as it is indicated in the billing.

The billing and the total timed code treatment minutes must be consistent. See Pub. 100-04, chapter 5, section 20.2 for description of billing timed codes; and


Treatment NoteSignature

Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment (i.e., the signature of Kathleen Smith, PTA, with notation of phone consultation with Judy Jones, PT, supervisor, when permitted by state and local law).

The signature and identification of the supervisor need not be on each Treatment Note, unless the supervisor actively participated in the treatment.


Treatment Notes Signature

Since a clinician must be identified on the Plan of Care and the Progress Report, the name and professional identification of the supervisor responsible for the treatment is assumed to be the clinician who wrote the plan or report. When the treatment is supervised without active participation by the supervisor, the supervisor is not required to cosign the Treatment Note written by a qualified professional.

When the responsible supervisor is absent, the presence of a similarly qualified supervisor on the clinic roster for that day is sufficient documentation and it is not required that the substitute supervisor sign or be identified in the documentation.


Treatment NoteModification to POC

If a treatment is added or changed under the direction of a clinician during the treatment days between the Progress Reports, the change must be recorded and justified on the medical record, either in the Treatment Note or the Progress Report, as determined by the policies of the provider/supplier.

New exercises added or changes made to the exercise program help justify that the services are skilled. For example: The original plan was for therapeutic activities, gait training and neuromuscular re-education. “On Feb. 1 clinician added electrical stim. to address shoulder pain.”


Treatment note Modification to POC

Documentation of each treatment may also include the following optional elements to be mentioned only if the qualified professional recording the note determines they are appropriate and relevant. If these are not recorded daily, any relevant information should be included in the progress report. Patient self-report; Adverse reaction to intervention; Communication/consultation with other

providers(e.g., supervising clinician, attending physician, nurse, another therapist, etc.);


Treatment Notes and Modification to POC

Significant, unusual or unexpected changes in clinical status;

services that are not part of the total treatment minutes be recorded, although they may be included voluntarily to provide an accurate description of the treatment, show consistency with the plan, or comply with state or local policies. The amount of time for each specific intervention/modality provided to the patient may also be recorded voluntarily, but contractors shall not require it, as it is indicated in the billing. The billing and the total timed code treatment minutes must be consistent. See Pub. 100-04, chapter 5, section 20.2 for description of billing timed codes


MODIFIERSNCCI #59 Modifier

Medicare Cap KX modifier


59 Modifier Use

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.


59 Modifier

NCCI edits define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances.

For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters.


59 Modifier Use Example: Column 1 Code/Column 2 Code

97140/97530 CPT Code 97140 – Manual therapy techniques

(eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

CPT Code 97530 – Therapeutic activities, direct (one-on-one) patient

contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

Policy: Mutually exclusive procedures Modifier -59 is:

Only appropriate if the two procedures are performed in distinctly

different 15 minute intervals. The two codes cannot be reported together if

performed during the same 15 minute time interval.


Medicare Cap KX

Use the KX modifier only in cases where the condition of the individual patient is such that services are APPROPRIATELY provided in an episode that exceeds the cap.

Routine use of the KX modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry. Be sure that documentation is sufficiently detailed to support the use of the modifier.


KX Modifier

COMPLEXITIES are complicating factors that may influence treatment, e.g., they may influence the type, frequency, intensity and/or duration of treatment.

Complexities may be represented by diagnoses (ICD-9 codes), by patient factors such as age, severity, acuity, multiple conditions, and motivation, or by the patient’s social circumstances such as the support of a significant other or the availability of transportation to therapy.


KX Documentation of Complexity of patients status and rehabilitative potential

Documentation supporting illness severity or complexity including, e.g.,

Identification of other health services concurrently being provided for this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse, respiratory therapy, social services, psychology, nutritional/dietetic services, radiation therapy, chemotherapy, etc.), and/ or

Identification of durable medical equipment needed for this condition, and/or Identification of the number of medications the beneficiary is talking (and type if known); and/or



If complicating factors (complexities) affect treatment, describe why or how. For example: Cardiac dysrhythmia is not a condition for which a therapist would directly treat a patient, but in some patients such dysrhythmias may so directly and significantly affect the pace of progress in treatment for other conditions as to require an exception to caps for necessary services. Documentation should indicate how the progress was affected by the complexity. Or, the severity of the patient’s condition as reported on a functional measurement tool may be so great as to suggest extended treatment is anticipated; and/or

Generalized or multiple conditions. The beneficiary has, in addition to the primary condition being treated, another disease or condition being treated, or generalized musculoskeletal conditions, or conditions affecting multiple sites and these conditions will directly and significantly impact the rate of recovery; and/or.



Mental or cognitive disorder. The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will directly and significantly impact the rate of recovery; and/or.

Identification of factors that impact severity including e.g., age, time since onset, cause of the condition, stability of symptoms, how typical/atypical are the symptoms of the diagnosed condition, availability of an intervention/treatment known to be effective, predictability of progress.



Mental or cognitive disorder. The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will directly and significantly impact the rate of recovery; and/or.

Identification of factors that impact severity including e.g., age, time since onset, cause of the condition, stability of symptoms, how typical/atypical are the symptoms of the diagnosed condition, availability of an intervention/treatment known to be effective, predictability of progress.


References1) Nagi, S. Disability concepts revisited: implication for prevention. In: Pope AM, Tarlov

AR, eds. Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press, 1991.

2) Guide to Physical Therapy Practice. 2nd ed. Physical Therapy. 2001;81:9-744.3) Jette AM. Physical disablement concepts for physical therapy research and practice.

Phys Ther. 1994;74:380-386.4) Ware JE Jr, Sherbourne CD. The MOS 36-item short form health survey (SF-36), I:

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Contact InformationDr. Charles Curtis MS, PT, DPT, MDT33 Orchard Place Little Silver, NJ [email protected]

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Documentation Clinical Notes - Copy (2)