- Medical Review
- Medical Review Focus Areas
- Service Specific Post-Payment Audits of Home Health PDGM Bills
- Service Specific Post-Payment Audits for Hospice Length of Stay > 730 Days
- Service Specific Post Payment Review of Psychotherapy, 60 Minutes with Patient – CPT 90837
- Service Specific Post Payment Review of Ambulance Transport and Mileage When Billed With Modifiers RJ, JR, RG, GR, NJ, JN, NG, GN
- Service Specific Post-Payment Audits of Home Health Value Code 17 Bills
- Announcing Service Specific Post-Payment Audits of Hyperbaric Oxygen (HBO) Services for J6 A Regions: IL, WI, and MN
- Service Specific Post-Payment Medical Review Notice Home Health PDGM (Edit 5AAGP)
- Service Specific Post Payment Review of Botulinum Injection, onabotulinumtoxina, 1 Unit – CPT J0585
- Service Specific Post Payment Review of Floweramnioflo, 0.1 CC – CPT Q4177
- Service Specific Post Payment Review of Grafix Prime (CPT Q4133)
- Service Specific Post Payment Review of Nonemergency Ambulance Transport and Mileage
- Service Specific Post Payment Review - Hospice GIP Services Over 7 Days (5ANLP) for JK A Regions: NY/CT, MA, ME, NH/VT and RI
- Service Specific Post Payment Review of Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post Payment Review of Fluoroscopic Guidance for Needle Placement - CPT 77002
- Service Specific Post Payment Review of Computed Tomography, Abdomen and Pelvis with Contrast Material(s) - CPT 74177
- Service Specific Post Payment Review of Darbepoetin Alfa Injection, 1 microgram (Non-ESRD Use)
- Service Specific Post Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy With Therapeutic Exercise – CPT 97113
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with Length of Stay > 730 Days
- Service Specific Post Payment Medical Review Summary Results of Home Health Value Code 17 Bills
- Review Results For Service Specific Postpayment Review of Psychotherapy, 60 Minutes With Patient
- Service Specific Post-Payment Medical Review Notice Hospice with Length of Stay over 730 Days (Edit 5ANKP)
- Service Specific Post-Payment Audits of Hospice GIP Care, DOS 3/1/2020 and After
- Service Specific Post-Payment Audits of Home Health LUPA Claims
- Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, If Performed); First 20 Square Centimeters or Less– CPT 11042
- Service Specific Post-Payment Review of Tangential Biopsy of Skin-Single Lesion CPT 11102 with Destruction-Premalignant Lesion-First Lesion CPT 17000
- Service Specific Post Payment Review Summary Results – Home Health PDGM Bills (Edit 5AAGP)
- Review Results for Service Specific Post-Payment Review of Artacent Wound, per Square Centimeter - CPT Q4169
- Review Results for Service Specific Post-Payment Review of Q4133 - Grafix Prime
- Announcing Service Specific Post-Payment Audits of Group Psychotherapy Services for J6 A Regions: IL, WI and MN
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with GIP > 7 Days
- Service-Specific Postpayment Medical Review Summary Results of Home Health PDGM Bills
- Review Results for Service Specific Post-Payment Review of Hyaluronan or Derivative - CPT J7326
- Review Results for Service Specific Post Payment Review of Hyaluronan or Derivative – CPT J7327
- Review Results for Service Specific Post-Payment Review of Fluoroscopic Guidance for Needle Placement
- J6_B_Review Results for Service Specific Post-Payment Review of J0585 – Botulinum Injection, Onabotulinumtoxina
- Review Results for Service Specific Post-Payment Review of Computed Tomography, Abdomen And Pelvis; With Contrast Material(s)
- Review Results for Service Specific Post-Payment Review of Therapeutic Procedure, 1 or More Areas, Each 15 Minutes; Aquatic Therapy with Therapeutic Exercise - CPT 97113
- Review Results for Service Specific Post Payment Review of Floweramnioflo
- Review Results for Service Specific Postpayment Review of Tangential Biopsy of Skin; Single Lesion CPT 11102 with Destruction, Premalignant Lesion; First Lesion CPT 17000
- Review Results for Service Specific Post-Payment Review of Darbepoetin Alfa Injection (Non-ESRD Use)
- Service Specific Post-Payment Review Summary Results – Home Health Homebound Criteria (Edit 5AAHP)
- Service Specific Post-Payment Review Summary Results – Hospice GIP Services Greater than 7 Days (Edit 5ANLP)
- Service Specific Post Payment Medical Review Summary Results of Hospice Services with General Inpatient Care, Date of Service 3/1/2020 and After
- Service Specific Post Payment Medical Review Summary Results of Home Health Low Utilization Payment Adjustment Claims
- Announcing Service Specific Post-Payment Audits of Individual Psychotherapy Services for J6 A Regions: IL, WI and MN
- Review Results for Service Specific Post Payment Review of Debridement, Subcutaneous Tissue (Includes Epidermis and Dermis, if Performed); First 20 Square Centimeters or Less – CPT 11042
- Service Specific Post Payment Review of Artacent Wound, Per Square Centimeter - CPT Q4169
- Service Specific Post-Payment Audits of Hospice GIP Care
- Service Specific Post Payment Review of Hyaluronan or Derivative - HCPCS J7326, J7327
- Skilled Nursing Facility Education Center
Daily Treatment Notes Requirement for Inpatient SNF Services
The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-2, Medicare Benefit Policy Manual, Chapter 15 is the primary source for therapy documentation instructions. Only if a therapy service, in a different location, has “different” requirements, the Medicare Benefit Policy Manual, Chapter 15 “does not apply”. However, if the other sections of the manual are silent on the topic, then the Medicare Benefit Policy Manual, Chapter 15 does apply.
The manual (CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.B.) states, “Specific policies may differ by setting. Other policies concerning therapy services are found in other manuals. When a therapy service policy is specific to a setting, it takes precedence over these general outpatient policies. For special rules on:
- CORFs - See CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 12 of this manual and also CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5;
- SNF - See CMS IOM Publication 100-02, Chapter 8 of this manual and also CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, for SNF claims/billing;
- HHA - See CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7 of this manual, and CMS IOM Publication 100-04, Medicare claims Processing Manual, Chapter 10;
- Group Therapy and Students - See CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230;
- Arrangements - CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 10.3;
- Coverage is described in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1; and
- Therapy caps- See CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2, for a complete description of this financial limitation.”
Therefore, a daily therapy treatment note is needed as a described in the CMS IOM Publication 100-2, Medicare Benefit Policy Manual, Chapter 15, Section 220 (regardless if a daily therapy service is provided in a SNF, CORF, IRF, HHA or outpatient program).
Second, the issue of “specificity” of what is required in a daily treatment note is addressed in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.15.E. The manual states, in relevant part, “The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service.”
The MAC should not “dictate” the format of the report. The therapist can provide the treatment note in any format, as long as it provides “sufficient documentation” (42 CFR) for the services provided.
Additionally, the matrix log is insufficient as “daily documentation.” The manual requires the documentation be provided for “every treatment day”, and a “matrix log” does not provide sufficient documentation to “justify the use of the billing codes” since a matrix typically only has the billing code and the time of the code. There is no justification for the use of the code. Since the matrix log only has codes and time, it does not “justify” the service was a “record of all treatments and skilled interventions that are provided” and does not describe “all treatments”, nor does it support that that daily treatment was “skilled”.
Reviewed 5/17/2023
Targeted Probe and Educate Manual
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Targeted Probe and Educate Manual
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Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
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Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.
Targeted Probe and Educate Manual
The preferred method to submit Medical Records is NGSConnex:
Visit our Contact Us page for other methods of submission.