Reminders: Medical record documentation for physical and occupational therapy

In conducting audits, we’ve found that the medical record documentation we receive from hospitals and physical therapy facilities for outpatient services isn’t always complete or legible.

Here are some important reminders to ensure that the information you submit is in compliance with BCBSM documentation guidelines for physical therapy and occupational therapy services:

Documentation must be legible. If we can’t read it, we can’t decide whether the services billed to BCBSM were appropriate. Keep in mind that the signature and credentials of the therapist providing the services must also be legible.

The physician orders (for the initial 30 days and any subsequent months of the treatment period) must include the following:

• Date of the order
• Diagnoses
• Frequency of treatment
• Specific duration of treatment
• Type and focus of treatment (modalities) to be provided
• Physician signature date (We will accept a legible fax date.)

For a list of the complete requirements, refer to the “Documentation Guidelines” chapter of your BCBSM provider manual. (See box at right.)

For continuing physician orders (renewed plan of care), include the dates of service for which the 30-day continuation is requested (e.g., the recertification period). This allows us to determine whether the physician has signed it in a timely manner. As long as the physician signs it within the recertification period, the order is considered valid and timely. If there is no specified date range, then the date of the physician’s signature becomes the new starting date of the 30-day coverage period.

Physician orders must be signed and dated within the 30-day treatment period. If it is signed and dated outside of this period, it will not be considered valid.

Physician orders are only valid for 30 days. Even if the physician orders therapy services for more than 30 days, the order will only be considered valid for 30 days.

Documentation of each treatment session billed to BCBSM (daily progress note or flow chart) must include the patient’s response to treatment. For a list of the complete requirements, refer to the “Documentation Guidelines” chapter of your BCBSM provider manual.

The monthly progress summary must be documented in the medical record at least once every 30 days to summarize the patient’s response to treatment. The monthly progress summary also can be used to meet the physician communication requirement, which specifies that the physician and therapist must communicate with each other about the patient’s progress every 12 visits or 30 days. In addition, the summary can be used as a subsequent physician order for continuing services, as long as the other necessary requirements are met. The summary should measure progress achieved and any resetting of goals for future achievement.

Monthly progress summaries must be authored by the therapist. Therapy assistants may contribute to the monthly progress summaries by documenting data collection or by providing information other than patient assessments.

The evaluation documentation must include statements of the goals established for the patient:

• For occupational therapy services, this includes documentation of reasonable functional activities of daily living short- and long-term goals.
• For physical therapy services, this includes documentation of treatment goals (therapeutic goals that are appropriate for the patient, the diagnoses, rehabilitation potential and the treatment to be provided).

Documentation of the therapy evaluation must include the functional level prior to the onset of the current illness, injury or exacerbation. This will provide the information to determine whether services are appropriate and medically necessary.

When preparing for an audit appointment, remember to provide the documentation for the entire treatment episode. If only one or two months of the treatment episode were selected for the audit sample, we still will want to review the entire record in order to gain a complete understanding of the patient’s response to treatment.

Note: These reminders are not intended to override any published BCBSM guidelines.

If you have questions about the information in this article, call Debra Amross, Utilization Review, at 313-448-1284 or send her an email at damross@bcbsm.com.