Poor Documentation – The Reason Your Visits are Being Denied by Medicare

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While most documentation at FTS is thorough and compliant, the occasional mishap occurs when Medicare or private insurers deny payment because of poor documentation.  The purpose of this post is to prevent those denials.  Listed below are 11 elements that must be included in documentation and a few tips to improve compliance.  These 11 elements are listed in Medicare denial letters and I do my best to describe the elements below.  

Hint:  Element #7 and #9 are the most common reasons FTS therapists are denied!

1. Reason for Referral

Make it clear in your documentation why the patient is being referred to home health and how the patient would benefit.

2. Diagnosis/condition being treated

The diagnosis must be stated in each visit documented.  Occasionally, the diagnosis will not be included in the Zuum app which will require searching through the Patient tab of HCNet in the General Notes section.  In Kinnser, select the patient’s name under My Patients, then click View and Patient Profile.  If the diagnosis is unclear, a specific PT or OT diagnosis needs to be stated i.e. upper/lower extremity weakness, impaired ability to transfer, decreased endurance with ambulation, pain with location, joint ROM deficits, dyspnea on exertion, etc.  In HCNet, the diagnosis will automatically generate on the note once the SOC or Recert OASIS is in transmitted status.  This can take up to a week after the SOC so if you are building from a previous note before the OASIS is transmitted, it will not automatically generate.  Insert a new note from scratch and the diagnosis will be in the medical necessity and home bound review section.

3. Prior level of function (PLOF)

PLOF is the status of functional abilities prior to the condition causing the need for rehabilitation services.  Including the patient’s PLOF will strengthen documentation by addressing medical necessity.  Good details to document on the patient’s PLOF at evaluation include:

  • Ambulation distance, amount of assistance needed to ambulate, assistive device being used for ambulation

  • How much assistance needed for each specific ADL
  • The patient’s ability to drive
  • Living situation: home alone/with family, ALF, senior apartment complex, etc.

4. Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring progress. 

Physical baseline data at the time of evaluation can be described in objective tests, amount of assist needed with ADLs/IADLs, etc.  These baseline physical measurements should be documented and compared to the patient’s PLOF.  If the current level of function is hindered compared to the prior level of function, this would be category to address in the plan of care and goals for the patient.  Cognitive baseline data is addressed in checkboxes in HCNet and Kinnser and is a requirement for each visit documented.

5. Current level of function

The patient’s current level of function should compare clearly to the documented PLOF.  For example, a patient was previously able to ambulate community level distances of 500 feet independently.  Now the patient’s current level of function is 50 feet of ambulation with minimum assistance.  Both should be documented, and in this scenario, gait training should be addressed in the patient’s plan of care and goals.

6. Objective measurements such as strength, ROM, pain, ADL level, and edema

Every evaluation and reevaluation should include objective measurements.  Good examples include: manual muscle tests, goniometry ROM measurements, TUG test, Tinetti test, Functional Reach, 30 second Sit to Stand Test, Berg Balance Test, distance of ambulation, edema grade etc.  The amount of assistance with transfers, bed mobility, specific ADLs, gait training, etc. should also be included.  Each test should consistently be performed at eval and each reeval to show progression or regression in that category.

7. ***Treatment techniques/modalities selected for treating current illness or injury***

Copy and pasting the same details from visit to visit is a very common reason for denial in regular and evaluation visits.  In HCNet, this is most commonly done in the Medical Necessity and Home Bound Review portion when building from the previous note.  The documentation in this box should include the details of a SOAP Note (Subjective, Objective, Assessment, Plan).  While the format of this box is left up to the discretion of the therapist, all four components of the SOAP note must be included.  No portion of the SOAP note should be the same visit to visit.  This website describes the SOAP note in more detail.  https://www.physio-pedia.com/SOAP_Notes

8. Limitations which may influence the length of treatment

While the Medicare minimum requirement is 30 minutes for a billable visit, most agencies prefer the visit time to be 45-60 minutes.  If the visit is shorter than 45 minutes, there should be documentation stating why.  Some agencies have a specific minimum time-limit.  This will be stated in red font on the Zumm app under Important Notes.

9. ***Short and long-term goals stated in objective measurable terms, and their expected date of accomplishment***

This is the most common reason for denial!  Long-term goals (LTG) and short-term goals (STG) must be updated at every eval and reeval.  The timeframe to achieve each goal must be documented in one of three types of measurements: number of visits, number of weeks, or an expected date of accomplishment.  In order for a patient to be eligible for therapy, at least one LTG and one STG that is not met must be documented.  Currently, it is required to document goals in two separate locations in HCNet.  First, each eval must begin with selecting checkboxes for all orders, goals, and DC plans under the Assessment tab.  The second location of documenting goals should occur in the Baseline/Reeval portion of the note and each should be typed out in its entirety.  For this LTG and STG section in HCNet, it is required to state the expected date of accomplishment for each goal.  The expected date of accomplishment must be updated at every reeval for each goal.  If the patient is still progressing to an unmet goal at the time of reevaluation, please clarify by documenting something like “Ongoing – Not Met” next to that goal.  If the goal is met, please document “Met” next to the goal.  There must be at least one unmet LTG and STG for every reeval.  LTGs and STGs can be added and/or adjusted to be more appropriate for the patient’s POC at each reevaluation.  Please clarify if the objectivity of a goal is adjusted by writing “MODIFIED” next to it.  If all LTG and STG are met, the patient should be discharged. 

10. Frequency and duration of therapy

Eval and reeval visits require documentation stating the frequency with the effective date.  The frequency with the effective date should be documented in three locations for each eval and reeval visit.  Those three locations include the documented note, a verbal order, and in the Zuum app.

11.  Re-assessments must be performed at least every 30 days to be a qualified physical/occupational therapist.  The 30-day clock begins with the first therapy’s visit/assessment/measurement/documentation of the PT and/or OT.

The PT/OT must complete a reevaluation at least every 30 days.  The supervising therapist and assistant must communicate for scheduling the 30-day reeval.  This can easily be done in the Zuum app messaging feature.  At the end of the 60-day certification period, a recert visit must be performed to continue seeing the patient into the next 60-day cert period.  The recert visit must be completed within the last 5 days of the cert period.  If it is not completed inside that 5-day window, a new eval must be documented for the first visit in the new cert period. 

More recently, HHCCN & NOMNC signatures have become a requirement.  Medicare is now denying payment when these are not completed properly.  These forms are both in the patient’s folder in their home.  In HCNet, you can get a digital signature from the patient by clicking on the ESignature Forms. 

HHCCN (Home Health Change of Care Notice)
The PT/PTA, OT/COTA, and ST are all required to get an HHCCN form completed and signed anytime the frequency is decreased or discontinued early. If a termination involves the end of all Medicare covered care and no further care is being delivered by the agency, the only notice issued would be a Notice of Medicare Non-coverage (NOMNC). Medicare requires a copy to be left in the patient’s home.  This must be collected even if the RN plans to continue to see the patient

  • This form can be completed electronically in HCNet: 
    • From the home screen in HCNet, select “Add/Review Visit Notes”
    • Search for the patient’s name and select the appropriate one
    • Select “ESignature Forms” – A blue tab on the right side of screen
    • Scroll to bottom of screen and select “Create New HHCCN Form”
    • Adjust date to the appropriate day of therapy; Fill out comment box under “Item/Services” with physical therapy services or home health services
    • Select Sign and have the patient sign the box and click sign again to save the signature
    • Select “Add/Save HHCCN Form”
    • NOMNC (Notice of Medicare Non-Coverage)

The PT/PTA, OT/COTA or ST must get this form completed and signed 5 days before the patient is to be discharged from the agency. If that is not possible and doesn’t happen then this form should be completed and signed at the discharge visit.  This form should only be completed if the patient is being completely discharged from the agency and the RN nor any discipline does not plan to continue.  Medicare requires a copy to be left in the patient’s home.

  •  This can be done electronically in HCNet: 
    • From the home screen in HCNet, select “Add/Review Visit Notes”
    • Search for the patient’s name and select the appropriate one
    • Select “ESignature Forms” – A blue tab on the right side of screen
    • Scroll to bottom of screen and select “Create New NOMNC Form”
    • Type Home Health Services or physical therapy, etc.
    • Select Sign and have the patient sign the box and click sign again to save the signature
    • Select “Add/Save NOMNC Form”

Reasons for Verbal Orders:

  • Missed Visits – if there is a missed visit during the week, please insert VO to explain why it was missed
  • Vital Signs outside of normal parameters – In HCNet, this will be completed automatically once the note is submit complete.  Please leave a message with the referring physician to notify what the vital signs were.  A call to the agency is not necessary unless specified in Zuum.
  • New frequency or any change in frequency – A VO with the frequency and effective date must be entered at any initial eval, recert, or reeval where there is a frequency change.
  • Discharge, Non-Admit and Eval Only – A DC visit or non-billable DC must have a VO stating why the DC occurred.  Non-Admitting a patient means an evaluation was not completed and it is non-billable which requires a VO.  An Eval Only visit means an evaluation was completed and the patient is not appropriate to continue which is a billable visit and must have a VO stating why the patient will not be seen. 

Please review the Therapist Training Manual on the FTS website if you need further clarification on any of these items.  The Manual can be found on the FTS website under forms: https://www.foremantherapyservices.com/therapistforms/.  The training videos are also great to revisit when questions come up: https://www.foremantherapyservices.com/trainingvideos/.  I hope all this information allows us to keep our documentation compliant and gives us a better understanding on why Medicare would deny payment for any inadequate documentation.  We want to do our best to keep our agencies and patients happy!

Matt Hurlbutt, PT, DPT