Bottom Line: Document It Correctly With This Glossary If your required Medicare paperwork has any errors, your payment may be in jeopardy. Understanding this list of terms will help you minimize mistakes and avoid rejected claims. Bottom Line
Bottom Line  |   July 01, 2013
Bottom Line: Document It Correctly With This Glossary
Author Notes
  • Lisa Satterfield, MS, CCC-A is ASHA director of health care regulatory advocacy.
  • Gennith Johnson, MA, CCC-SLP is ASHA associate director of health care services.
Article Information
Practice Management / Bottom Line
Bottom Line   |   July 01, 2013
Bottom Line: Document It Correctly With This Glossary
The ASHA Leader, July 2013, Vol. 18, 24-25. doi:10.1044/leader.FTJ7.18072013.34
The ASHA Leader, July 2013, Vol. 18, 24-25. doi:10.1044/leader.FTJ7.18072013.34
Functional outcome reporting and manual medical review are initiatives that have added complexity and sometimes confusion about documenting services to Medicare beneficiaries. And the Medicare policy manual makes the need for compliance abundantly clear: Medicare will reimburse for outpatient therapy services—or Part B therapy services provided in skilled nursing facilities—only when the patient's medical record and the information on the claim form consistently and accurately report covered services.
But Medicare terminology often makes it difficult for SLPs to understand the rules for documentation and reporting, much less follow them and demonstrate the skilled services they provide. These definitions, summarized from the "Medicare Benefit Policy Manual " (Chapter 15, Section 220.3), may help:
Evaluation is a comprehensive service that requires professional skills. It is based on objective measurements and subjective evaluations of a patient's performance and functional abilities. Evaluation is warranted, for example, for a new diagnosis or if a condition is treated in a new setting. Evaluation has an associated reimbursable billing code.
Sometimes, an evaluation is the only service an SLP provides to a Medicare beneficiary. In this case, the evaluation serves as the plan of care (see below) if it contains a diagnosis or a description of the condition that the referring physician or nonphysician practitioner can use to make a diagnosis. Therefore, when evaluation is the only service, the physician's referral and the SLP's evaluation are the only documentation Medicare requires for reimbursement and for functional outcome reporting.
A re-evaluation is billable as an evaluation when an assessment indicates a significant change in patient condition that was not anticipated in the plan of care.
Assessment has a specific meaning different from evaluation in Medicare terminology. Assessment has no separate billing code; it is part of the skilled services delivered by a clinician during a treatment session. Assessment uses clinical observation, patient self-report and objective data to make clinical judgments about progress toward goals or to determine the need for a formal evaluation.
Plan of care is the written treatment plan, which includes diagnoses; long-term treatment goals; and type, amount, duration and frequency of therapy services. The plan must be established before treatment begins and consistent with the related evaluation, which may be attached to the plan and is considered part of it. A patient receiving services from more than one discipline—occupational or physical therapy, for example—must have a separate plan for each therapy discipline.
Certification/recertification is the approval from the physician or nonphysician practitioner for the plan of care. The SLP must receive this approval within 30 days of initial treatment. Certification requires a dated signature on the plan of care, or other document that indicates approval of the plan of care. Recertification is required at least every 90 days for a plan of care that does not change substantially. Recertification is required within 30 days of the initial treatment if the plan of care is modified significantly—for example, by adding a new condition, changing long-term goals or responding to changes in the patient's condition.
Functional reporting is a new Medicare requirement in 2013 for Medicare Part B claims. All providers, including SLPs, must report nonpayable G-codes and related modifiers to convey information about the patient's functional status at specified points during treatment. Providers must include these codes and modifiers in the plan of care and in the progress notes. (For more information, see G-Codes and Severity Modifiers for Claims-Based Outcomes Reporting.)
Progress notes provide ongoing justification for the medical necessity of treatment and the need for an SLP's skilled service. Medicare requires providers to record progress notes at least once every 10 treatment days. Progress notes must include assessment of improvement and/or extent of progress, plans for continuing treatment, reference to additional evaluation results, treatment plan revisions, and changes to long- or short-term goals. Progress notes also must include functional reporting, including the G-code with severity modifier and an explanation of the choice of modifier.
The discharge note—the final progress note—includes the required elements of the progress note. If the discharge is unanticipated, the clinician may base his or her judgments of the functional status at discharge on the treatment notes and verbal reports of the assistant or qualified personnel. The discharge note is the last opportunity to justify medical necessity for the entire treatment episode.
Only skilled therapy services may be billed under Medicare. They are defined as meeting the following two criteria:
  • They must be provided by the qualified professional and documented in the plan of care and progress notes.

  • They require the expertise, knowledge, clinical judgment and decision-making abilities of a clinician for safe and effective results. They cannot be provided independently by assistants, qualified personnel, caretakers or the patient.

Unskilled services are repetitive, reinforce previously learned skills, or maintain function in a maintenance program.
Treatment day is defined as a single calendar day on which treatment, evaluation and/or re-evaluation is provided. A single treatment day could include multiple visits or treatment sessions/encounters.
Treatment notes are a record for each treatment day. They create a record of skilled intervention and time of service to justify the billing codes used on a claim. Every treatment day must be documented, and every treatment service must include date, service provided, total time in treatment and provider signature. There is no standard format for treatment notes.
For more information on documentation requirements for SLPs in health care settings, visit our documentation page.
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July 2013
Volume 18, Issue 7