Physician Documentation Tips
Recently, a reminder was sent to providers with results of an Office of Inspector General (OIG) audit, which found non-compliance in a large percentage of inpatient rehabilitation claims. I do not know if there was an implied message behind the warning, or if it was just a friendly reminder. In either case, it seems like the right time to dust off the cobwebs and review the Medicare documentation requirements for inpatient rehabilitation providers.
Lisa Werner, MBA, MS, SLP Director of Consulting Services, Fleming-AOD, Inc.
The OIG report, states that a large percentage of requested records did not meet eligibility requirements for an inpatient rehabilitation stay due to missing documentation. In the past, these were referred to as technical errors or lack of proof of medical necessity. The following list of requirements can be shared with physicians to ensure awareness of the requirements for Medicare patients. CMS Requirements 1. Sign the pre-admission screening no more than 48 hours prior to the patient’s admission. 2. Assess the patient within 24 hours of admission and complete the H&P. 3. Complete the overall plan of care by the end of the fourth day of rehab. 4. Complete at least three documented face-to-face visits per week (in addition to the H&P). 5. Include updates on medical and functional progress and participation in your progress notes at least three times per week. Medical Necessity 1. Thoroughly document the conditions that will be managed. 2. Discuss the strategies and interventions necessary to manage those conditions. 3. Be explicit about the patient’s need for medical management by stating what you saw, thought, and did during your exam. 4. Mention function and state whether the patient’s progress or lack of progress is meeting your expectations. 5. Note all order changes and tests in the progress notes to reflect close medical management. An auditor may not put these items together or read far enough into a record to see orders.
AMRPA Magazine / August 2020 13
