Palmetto GBA updated their PT and OT local coverage determinations (LCDs) on 3/12/15 to include provider education and guidance regarding documentation of restorative versus maintenance therapy. The PT utilization guideline states “Whether the plan is rehabilitative/restorative or maintenance should be indicated on the CMS-485 or on the OASIS M1800-M1910 with reference to ADL/IADL’s and current ability.” The OT utilization guideline states “It would be very helpful to Palmetto GBA if providers would indicate in Field 21 of the Form CMS-485 (if used) or Orders section of the plan of care whether the therapy is rehabilitative/restorative or maintenance. This information could also be added to the OASIS M1800-M1910, references ADLs/IADLs (current ability).”

This once again necessitates a change in the way a therapist documents interventions and goals.

While the letter of the law is saying that therapy orders need to be identified as rehabilitative/ restorative or maintenance on the 485, it is recommended that therapy orders also be labeled on all therapy evaluations, re-evaluations, and functional reassessments. Getting in this habit will allow fiscal intermediaries, CERT contractors, and other auditing bodies to have a clear idea of your intent in providing therapy services and avoid denials based on misunderstandings.

Other tips to bulletproof your documentation:

  • All progress notes should have “objective measurements and functional accomplishments” – avoid generalizations like “Doing well”, “Improving”, “Less pain”, “Increased range of motion”, “Increased strength”, “Tolerated treatment well”, “Continue with POC” (Examples from PT LCD)
  • Each progress note must stand on its own – meaning in the absence of all other notes it would demonstrate the patient’s condition, need for therapy services, medical necessity, homebound status, and skilled services provided
  • Each progress note must contain (per the Palmetto PT LCD):
    • The history and physical exam pertinent to the day’s visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit, and
    • The patient/caregiver’s response to the skilled services provided, and
    • The plan for the next visit based on the rationale of prior results, and
    • A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences,
    • The complexity of the service(s) to be performed, and
    • Any other pertinent characteristics of the beneficiary or home
  • Make sure your notes are legible – if the auditing professional cannot read your note, your claim will be denied simply for illegibility
  • Make sure the OASIS data is consistent with the patient’s level of function and supports the need for therapy services

One final reminder (and this is critical) if the patient’s condition changes such that the therapy service you are providing changes from restorative / rehabilitative to maintenance, you must make sure your documentation clearly states and supports such a change and you must write an order to change the type of treatment you are providing. It would be wise to do a new evaluation with updated interventions and goals.

therapyBOSS works hard to help ensure you have the tools at your disposal to create compliant documentation with ease. A system update is being considered to help designate orders as rehabilitative/restorative vs maintenance. In the meantime, you can add “Rehabilitative/Restorative therapy” or “Maintenance therapy” in the Therapy Interventions of your Care Plan to ensure complete clarity about your focus of care. These can be set up as a template for Physical Therapy and Occupation Therapy.

If you are looking for clarification about documentation, please check out the LCD links below. You can also sign up for e-mail updates and Palmetto will let you know when LCDs have been updated.

The complete Palmetto GBA Physical Therapy LCD

The complete Palmetto GBA Occupational Therapy LCD

Sign up for Palmetto GBA e-mail updates

Sign up for National Government Services e-mail updates

Sign up for CGS Administrators e-mail updates

Palmetto GBA covers home health and hospice services for Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee and Texas.

National Government Services covers Alaska, American Samoa, Arizona, California, Connecticut, Guam, Hawaii, Idaho, Maine, Massachusetts, Michigan, Minnesota, Nevada, New Hampshire, New Jersey, New York, Northern Mariana Islands, Oregon, Puerto Rico, Rhode Island, US Virgin Islands, Vermont, Wisconsin and Washington.

CGS Administrator covers Delaware, District of Columbia, Colorado, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia and Wyoming.