Here are answers to frequently asked questions about therapy services documentation

This article provides an update to information that was published in the May and June 2008 issues of The Record.

As part of Blue Cross Blue Shield of Michigan’s ongoing hospital outpatient auditing process, we often receive questions about our documentation guidelines for physical therapy, occupational therapy, and speech and language pathology services. Following are answers to some of these questions. The information below also applies to freestanding outpatient physical therapy facilities.

To access the provider manual chapter titled “Documentation Guidelines for Physicians and Other Professional Providers,” see the instructions at the end of this article.

Note: These responses are considered explanatory and aren’t intended to override any published Blue Cross guidelines.

Q: If a physician signs a therapy order but doesn’t include a signature date, does Blue Cross accept a “date received” (date received by the therapy provider) stamp?

A: Yes.

Q: If a signed physician order is faxed with no signature date, is the date the fax is received considered the order date?

A: Yes.

Q: Blue Cross policy states that the attending physician’s order must contain information on diagnosis and areas of the body to be treated. Would the written diagnosis on the therapy order — which, by definition, includes a body part — satisfy this requirement?

A: The diagnosis generally includes or implies the body part, so a separate statement of the affected area usually is not necessary. If the original diagnosis is very general, however, it might not be possible to identify the affected area. In this case, the therapy plan of care, completed at the initial evaluation, should be written to provide information about the part of the body being treated, specific interventions and the frequency and duration of treatments.

Q: How long are physicians’ orders for therapy services valid?

A: They expire after 90 days for physical therapy and occupational therapy services and after 120 days for speech and language pathology services unless a specific duration or certification period are specified. These limitations apply even if the order says “ongoing” or indicates a period of time longer than 90 or 120 days, respectively. After that, the physician must write a new order for continuation of PT and OT or speech and language therapy services.

Q: When a physician signs and dates a PT or OT order, does the order expire 90 days after the signature date or 90 days after the date of the first evaluation or treatment?

A: The date of the order may not be the same day the patient receives the initial therapy evaluation. Once the evaluation has been completed and the plan of care is sent to the physician for review and signature, the signed care plan is valid for 90 days from the first treatment date unless a specific duration or certification period are specified.

Q: What if the physician doesn’t sign the plan of care?

A: If the plan of care is not signed but includes all the documentation Blue Cross requires, we use the initial order to validate services for the first 90 days unless a specific duration or certification period is specified. The required documentation includes:

• Date of order
• Diagnosis
• Type and focus of treatment to be provided
• Body areas to be treated
• Frequency of treatment
• Specific duration of treatment
• Changes in treatment plan or orders to continue treatment (when applicable)
• Physician’s signature and signature date

Q: When is the renewal order for continuation of therapy services due?

A: The renewal order is due 90 days after the first treatment date — or sooner depending on whether duration or certification dates are specified.

Q: Suppose a physician signs and dates a therapy order on Nov. 1, 2016, indicating specific treatment duration of Nov. 5, 2016, to Dec. 5, 2016. If the patient’s therapy evaluation and treatment begins on Nov. 5, does the order expire on Nov. 30 or Dec. 5?

A: Use the dates specified for valid dates of service. The order expires on Dec. 5.

Q: Suppose therapy evaluation and treatment began on Nov. 5, 2016, with specific treatment dates of Nov. 5, 2016, to Dec. 5, 2016. The patient returns to the physician on Nov. 15, 2016, (before completing the therapy), and the physician signs and dates a renewal order specifying treatment dates of Dec. 6, 2016, to Jan. 5, 2017. When does the renewal order expire?

A: The most recent specified dates apply, so the order expires Jan. 5.

Q: Suppose a patient is currently authorized to receive treatment from Nov. 1, 2016, to Nov. 30, 2016, but a renewal order for continuation of therapy services is sent to the physician on Nov. 18, 2016. If the physician doesn’t sign it until Dec. 9, 2016, when are the new covered dates of service?

A: The renewed plan of care should include the dates of service for which the 90–day continuation is being requested. When treatment dates are specified, it doesn’t matter when the physician signs it, as long as it’s within the specified treatment period. If there is no specified date range, the date of the physician’s signature becomes the new starting date for the 90–day coverage period.

Q: Is it necessary to wait for a signed plan of care before initiating therapy?

A: If the initial referral order from the physician says “evaluate and treat,” the therapist has the option, based on the patient evaluation, to initiate treatment without waiting for the signed plan of care. Unless the initial order indicates “evaluate only,” the risk that the physician won’t sign the plan of care is relatively minor. Services shouldn’t be billed to Blue Cross, however, until the therapist receives the signed plan of care. In addition, if the therapist recommends an intervention that may be viewed as controversial by the physician, the therapist should communicate with him or her and obtain verbal approval before initiating treatment.

Q: Blue Cross requires that the therapist write a treatment note for each session billed for physical therapy, occupational therapy, and speech and language pathology patients. What should be included in the treatment note?

A: The treatment note, which may be documented in progress notes, a flow chart or grid system, must include the interventions that were provided and the patient’s response to care. Blue Cross recommends that indications of progress and ongoing functional status be included in the treatment notes more frequently than the summary progress note required every 30 days for PT and OT, and 60 days for speech and language pathology because auditors use these elements to determine continuing medical necessity.

Q: Blue Cross requires that the therapist write a treatment summary or progress note at least every 30 days for PT and OT, and 60 days for speech and language pathology patients. What should be included in the progress note?

A: The progress note should include all of the following:

• Date of the summary or progress note and the dates of service covered by the summary or progress note
• Specific and objective evaluation of the patient’s progress and response to treatment during the period
• Changes in medical status, which must be documented in clear, concise, objective statements
• Changes in mental status and level of cooperation, which must be documented in clear, concise, objective statements
• Changes in the treatment plan, including a rationale for the changes and information addressing the patient’s readiness for discharge from treatment
• The signature and credentials of the therapist assessing the patient’s progress

Q: Will this progress note also serve as the required communication between the therapist and the physician in charge?

A: Yes, but only if it includes all the elements listed above. Blue Cross requires that the therapist and physician communicate regularly — every 90 days for PT and OT, and every 16 visits or 90 days (whichever comes first) for speech and language pathology services.

Q: Does Blue Cross require the summary or progress note be written on the date the care was provided?

A: No. A summary or progress note may be a standalone document written on a date when treatment wasn’t provided.

Q: Is it permissible for the physical therapist assistant or occupational therapy assistant to help the physical therapist write the progress note?

A: Yes, but the physical therapist or occupational therapist must be the primary author. The PTA or OTA may contribute to the progress note through data collection or by providing information other than patient assessments.

Q: Suppose we have a patient with a 60-consecutive day Blue Cros rehab benefit plan, and a physician sees him during the 30 days from Nov. 1 to Dec. 1. We request a “continuation of therapy services” or renewal order for the patient. However, in the meantime, the physician goes out of town for two weeks. As a result, the patient doesn’t receive services and is placed on hold for 14 days due to lack of a signed renewal order. Is it possible to recapture the “on hold” days, which would exceed the 60-day limit?

A: No. According to “Physical Therapy, Occupational Therapy, and Speech and Language Pathology Benefit”, a chapter in the Hospital — outpatient provider manual (see directions at the end of this article), when counting 60 consecutive calendar days per condition, “days are counted starting with the first date of treatment and ending 60 days later, regardless of how many services are provided during the 60-day period.” Coverage may vary under different contracts and for different groups but, in general, extensions aren’t allowed. From a clinical perspective, however, interruptions in care or delays in service continuity may be constructive and reasonable for the overall rehabilitation of the patient.

Q: Suppose we have a patient with a spinal cord injury who is stable, doing well in rehab and progressing toward independence at the time of both the required 30- and 60-day therapy reassessments. If the therapist determines that patient needs an additional 60 days of treatment to reach functional independence but the patient is unable to schedule a follow-up visit with the physician until 60 days later (120 days after the initial evaluation), will the patient’s services be covered?

A: The online provider manual states that “for physical therapy beyond 60 days, the physician must personally evaluate the patient every 90 days to determine whether continued therapy is needed and document the medical necessity for continuing the treatment.” Based on this scenario, without the personal evaluation by the physician at the 90-day and 120-day mark, services would be denied.

Q: How does Blue Cross make a final audit determination? Is there any way to appeal denied services?

A: Blue Cross makes an audit determination based on a review of the medical record documentation and an itemized bill. Providers who receive a service denial may appeal the audit findings. In such cases, clinicians would need to provide additional documentation that supports the medical necessity for continuing therapy services.

Hospital outpatient program and free standing outpatient physical therapy facility’s staff can direct their questions by sending an email to Utilizationreviewdept@bcbsm.com.

For more information on typical physical therapy, occupational therapy, and speech and language pathology therapy benefits, please consult the electronic provider manual.

• Log in to web-DENIS.
• Click on BCBSM Provider Publications and Resources.
• Under View a Provider Manual, select Hospital — outpatient.
• Click on Get Info.
• Scroll down; click on Physical Therapy, Occupational Therapy, and Speech and Language Pathology Benefit.