The Medicare Monthly Review, MMR-2011-01, January 2011 - CGS

ased on documentation provided to support medical necessity of services recorded on the MDS for theclaim period billed.”Key PointsThe beneficiary’s medical record should contain all documentation to fully support the medical necessityfor the RUG code/services billed. In the case of a rehabilitation RUG, the provision of therapy servicesmust be supported by the following:• Therapy logs must document the actual minutes of therapy the beneficiary participated in per dayo Logs should be provided for the look back period for each MDS assessment related to the claimdates of service being reviewed; and for the claim dates of service being reviewed• Documented time should be a record of the time the beneficiary spent receiving therapyo Minutes should be actual (NOT rounded)o Time should be recorded in minutes (NOT units)• Documented time should NOT include the following:o The initial evaluationo Rest breaks taken by the beneficiary during the therapy sessiono The therapist’s time spent documenting the initial evaluation, treatment notes and/or progressnoteso The therapist’s time spent establishing the plan of treatment and short term/long term goalsPer the National Government Services local coverage determination for Skilled Nursing Facilities(#L26861), http://apps.ngsmedicare.com/sia/ARTICLE_A46184.htm “To support the provision of therapyservices the documentation in the medical record must include entries of attendance, scheduled activitiesand participation at each session. Then a weekly progress note is acceptable from the therapist basedupon the information documented for each session.”In addition, the services must be directly related to an active treatment plan established by a therapistand approved by the physician. The services must be of a level of complexity that the judgment,knowledge, and skills of a therapist are necessary to safely provide the services. There must be areasonable expectation that the patient will improve in a reasonable and generally predictable period oftime. Finally, the amount, frequency, and duration of the services must be reasonable and necessary forthe treatment of the patient’s condition.When a claim is selected for review, all pertinent medical record documentation associated with the datesof service will be reviewed by the medical reviewer. The reviewer will determine if the types of service,as well as the intensity of services are appropriate based on the clinical picture that the medical recordprovides.Sources:• Section 1833(e) of Title XVIII of the Social Security Act;http://www.ssa.gov/OP_Home/ssact/title18/1833.htm• Section 1862(a)(1)(A) of Title XVIII of the Social Security Act;http://www.ssa.gov/OP_Home/ssact/title18/1833.htm• 42 CFR Sections 409.30-409.33; http://law.justia.com/us/cfr/title42/42-2.0.1.2.9.4.35.1.html• CMS Internet-Only Manual (IOM), Publication 100-02, Chapter 8;http://www.cms.gov/manuals/Downloads/bp102c08.pdfCPT codes and descriptors are only copyright 2010 American Medical Association (or such other date publication of CPT)The Medicare Monthly Review 20 MMR 2011-01, January 2011