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Essential Forms forTherapists

HCPro, Inc., with Kate Brewer, PT, MBA, GCS

Essential Forms

forTherapists

Essential Forms for Therapists is published by HCPro, Inc.

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Essential Forms for Therapists iii

C o n T E n T s

s E C T i o n 1

Therapy Documentation Forms ......................................................................................................... 1

Form 1: Inpatient rehab patient assessment instrument ............................................................ 2

Form 2: MD referral ........................................................................................................................ 5

Form 3: Medical necessity documentation form ......................................................................... 6

Form 4: Occupational therapy flow sheet .................................................................................... 7

Form 5: Physical therapy and occupational therapy evaluation ................................................ 8

Form 6: Physical therapy daily notes ............................................................................................ 9

Form 7: Physical therapy flow sheet ........................................................................................... 12

Form 8: Plan of treatment for outpatient rehabilitation............................................................ 13

Form 9: Rehabilitation therapy registration form ..................................................................... 15

Form 10: Speech-language pathology flow sheet ..................................................................... 16

Form 11: Speech therapy evaluation ........................................................................................... 17

Form 12: Therapy checklist .......................................................................................................... 18

Form 13: Therapy discharge note ............................................................................................... 20

Form 14: Updated plan of progress for outpatient rehabilitation ........................................... 21

s E C T i o n 2

Managed Care.................................................................................................................................... 23

Form 15: Managed care competitor analysis ............................................................................. 24

Form 16: Managed care market analysis .................................................................................... 25

Form 17: Managed care network analysis ................................................................................. 26

Form 18: Managed care rehabilitation quotient ........................................................................ 27

Form 19: Therapy progress report for managed care plans .................................................... 29

s E C T i o n 3

Personnel Management & Human Resources ............................................................................... 31

Form 20: Goal setting worksheet ................................................................................................ 32

Form 21: Insurance labels ............................................................................................................ 33

Form 22: Intercommittee action request .................................................................................... 34

Form 23: Job description template .............................................................................................. 35

Form 24: Meeting attendance record .......................................................................................... 38

Form 25: Meeting checklist .......................................................................................................... 39

Form 26: Meeting minutes ........................................................................................................... 41

Form 27: New manager foundation knowledge/skills assessment .......................................... 42

Form 28: Patient satisfaction survey ........................................................................................... 43

Essential Forms for Therapistsiv

Form 29: Performance review template ..................................................................................... 44

Form 30: Professional development ............................................................................................ 60

Form 31: Professional development career path ....................................................................... 61

Form 32: Therapist credentialing profile .................................................................................... 62

Form 33: I-9, Employment eligibility verification ...................................................................... 64

Form 34: W-9, Request for taxpayer ID number and certification .......................................... 68

s E C T i o n 4

Essential CMs Forms......................................................................................................................... 73

Form 35: Advance beneficiary notice – general ......................................................................... 74

Form 36: Advance beneficiary notice – laboratory ................................................................... 75

Form 37: CORF facility request for certification to participate in Medicare program ......... 76

Form 38: CORF survey report ..................................................................................................... 78

Form 39: Fire safety report .......................................................................................................... 93

Form 40: Fire/smoke zone evaluation worksheet for healthcare facilities ........................... 108

Form 41: Medicare reconsideration request form .................................................................. 113

Form 42: Medicare redetermination request form .................................................................. 114

Form 43: Notice of denial of medical coverage ....................................................................... 115

Form 44: Notice of denial of payment ....................................................................................... 117

Form 45: Notice of exclusions from Medicare benefits .......................................................... 119

Form 46: Notice of Medicare noncoverage .............................................................................. 120

Form 47: Outpatient therapy survey report ............................................................................. 121

Form 48: Patient request for medical payment – English version ......................................... 136

Form 49: Patient request for medical payment – Spanish version ........................................ 138

Form 50: Provider tie-in notice .................................................................................................. 140

Form 51: Rehab hospital criteria worksheet ............................................................................ 141

Form 52: Rehab unit criteria worksheet ................................................................................... 145

Form 53: Request for certification in Medicare and Medicaid .............................................. 151

Form 54: Request for Medicare hearing by an administrative law judge ............................ 153

Form 55: Skilled nursing facility ABN ...................................................................................... 155

Form 56: Transfer of appeal rights ............................................................................................ 156

Contents

Essential Forms for Therapists v

Additionally on the CD-RoM you will find the following forms:

s E C T i o n 5

Job Descriptions

Form 57: Accounting manager

Form 58: Accounts payable assistant

Form 59: Accounts payable manager

Form 60: Administrative assistant

Form 61: Billing assistant

Form 62: Coder – medical records

Form 63: Coding supervisor

Form 64: Director, patient financial services

Form 65: Human resources assistant

Form 66: Human resources coordinator

Form 67: Job description template

Form 68: Medicare billing specialist

Form 69: Occupational therapist

Form 70: Occupational therapist, no degree

Form 71: Occupational therapy assistant

Form 72: Outpatient rehabilitation director

Form 73: Payroll assistant

Form 74: Payroll clerk

Form 75: Physical therapist

Form 76: Physical therapist, no degree

Form 77: Physical therapy assistant

Form 78: Receptionist – HR assistant

Form 79: Rehab manager, VNA

Form 80: Risk manager

Form 81: Secretary

Form 82: Senior rehab therapist

Form 83: Speech-language therapist

Form 84: Speech therapist

Form 85: Third-party payer

CD-RoM contents

Essential Forms for Therapistsvi

s E C T i o n 6

Performance Reviews

Form 86: Accounting manager

Form 87: Accounts payable assistant

Form 88: Accounts payable manager

Form 89: Administrative assistant

Form 90: Billing assistant

Form 91: Coder – medical records

Form 92: Coding supervisor

Form 93: Director, patient financial services

Form 94: Human resources assistant

Form 95: Human resources coordinator

Form 96: Medicare billing specialist

Form 97: Occupational therapist

Form 98: Occupational therapist, no degree

Form 99: Occupational therapy assistant

Form 100: Outpatient rehabilitation director

Form 101: Payroll assistant

Form 102: Payroll clerk

Form 103: Performance review template

Form 104: Physical therapist

Form 105: Physical therapist, no degree

Form 106: Physical therapy assistant

Form 107: Receptionist – HR assistant

Form 108: Rehab manager, VNA

Form 109: Risk manager

Form 110: Secretary

Form 111: Senior rehab therapist

Form 112: Speech-language therapist

Form 113: Speech therapist

Form 114: Third-party payer

CD-RoM contents

Essential Forms for Therapists �

In this section, you will find the following forms:

Therapy Documentation Forms

s E C T i o n 1

Form 1: Inpatient rehab patient assessment instrument

Form 2: MD Referral

Form 3: Medical necessity documentation form

Form 4: Occupational therapy flow sheet

Form 5: Physical therapy and occupational therapy evaluation

Form 6: Physical therapy daily notes

Form 7: Physical therapy flow sheet

Form 8: Plan of treatment for outpatient rehabilitation

Form 9: Rehabilitation therapy registration form

Form 10: Speech-language pathology flow sheet

Form 11: Speech therapy evaluation

Form 12: Therapy checklist

Form 13: Therapy discharge

Form 14: Updated plan of progress for outpatient rehab

Essential Forms for Therapists

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INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

Form CMS-10036 (01/06) 1

Form ApprovedOMB No. 0938-0842

Form 1inpatient rehab patient assessment instrument



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inpatient rehab patient assessment instrument (cont.)



Form CMS-10036 (01/06) 2

Form 1


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inpatient rehab patient assessment instrument (cont.)



Form CMS-10036 (01/06) 3

Form 1

Source: The Centers for Medicare & Medicaid Services



�

Professional ReferralFor Medical Consultation

Business NameAddress:

Phone: ( )FAX: ( )

INSERT LOGO

Dear (insert physician’s name), We are pleased to refer the following patient to you for medical consult:

Name: ___________________________ DOB: _______ Phone #: ______________________________

This patient is a client of __________________ and is seeking medical referral for: ______________________________________________________________________________________

Therapist’s impression:______________________________________________________________________________________

Previous assessment/treatment provided by ______________________________:______________________________________________________________________________________

______________________________________________________ ______/_____/______Therapist signature Date

Referring therapist: _____________________________ Phone #: ______________________________

We look forward to working with you if further rehabilitation services are needed for this client. Please provide the following information if applicable, and return to ________________________ via fax or mail.

Medical diagnosis/Physician’s impression: ______________________________________________________________________________________________________________________________________

Precautionary information: ______________________________________________________________

❏ Continue therapy per plan of care

❏ Additional recommendations _________________________________________________________

❏ No additional therapy is needed at this time

______________________________________________________ ______/_____/______Physician’s signature Date

In addition to traditional outpatient orthopedic physical therapy, __________ provides the following specialty evaluations/programs:

❏ COMPREHENSIVE SPINAL MANIPULATION & REHABILITATION PROGRAM❏ FIBROMYALGIA EXERCISE PROGRAM ❏ VESTIBULAR REHABILITATION PROGRAM

**Please contact us if you would like more information on how we can assist you with rehab management of your patients**

MD referralForm 2

Source: Lynn Steffes, Steffes & Associates Consulting Group, LLC. Used with permission.


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Therapist name: _____________________________________

Date: ___________________

Patient’s name: ______________________________________

DOB: ___/____/_____ Age: __________ Sex: ______ (M/F)

_________________________________________________________________________________ Diagnosis:

_________________________________________________________________________________Code(s):

_________________________________________________________________________________Medical history and clinical assessment of needs:

Sensory/motor ability:

Functional status:

Cognitive ability:

Respiratory ability:

_________________________________________________________________________________Description of condition:

_________________________________________________________________________________Risk factors:

_________________________________________________________________________________Plan of care:

_________________________________________________________________________________Evaluation: Signature: __________________________________________

Date: ___________________

Medical necessity documentation formForm 3



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Client Name: MR #: Start of Care:

dd/mm

dd/mm

dd/mm

dd/mm

dd/mm

dd/mm

Plan of Treatment kb kb kb kb kb kb

❏ 97110 Therapeutic Exercise

❏ 97535 ADL Retraining

❏ 97530 Therapeutic Activities

❏ 97112 neuromuscular Reeducation

❏

❏

Signature Key:

Progress Note:

Source: Progressive Rehab Solutions. Used with permission.

occupational therapy flow sheetForm 4


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Patient name: DOB: Date:

Facility name: Facility ID: Facility phone number:

Therapist name:

Number of visits: Number of previous treat-ments:

Date of first visit:

Previous functional status and abilities

Strength

Range of motion

Pain intensity

Alignment

Ambulatory/gait/balance

Strength

Current functional status and abilities

Pain intensity

Alignment

Ambulatory/gait/balance

Reflexes

Range of motion Functional outcomes

Signature:_________________________________________ Date:_________________________

Physical therapy and occupational therapy evaluationForm 5



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Pt. Name: _____________________________ MR #: __________ Account #: _______________

Tx #: _____ Date: _____ Minutes in timed codes: _____ Charges: _____ Total Minutes: ______

S: Pain Level: ______/10, Type: _____________________________

Location: ______________________________________________ ❏ No Change ❏ Worse ❏ Improving ❏ See Comments

O: Treatment: Modalities: ____________ ❏ Flow Sheet ❏ Comments Therapeutic Exercise: ❏ Flow Sheet ❏ Comments Therapeutic Activities: ❏ Flow Sheet ❏ Comments Manual Therapy: ❏ Flow Sheet ❏ Comments Other: ________________ ❏ Flow Sheet ❏ Comments

A. Progressing toward functional goals: ❏ Yes ❏ No ❏ Comments

Skin normal appearance after modalities: ❏ Yes ❏ No ❏ Comments

P. ❏ Continue Current Tx ❏ Tx Changes ❏ See Comments

Tx #: _____ Date: _____ Minutes in timed codes: _____ Charges: _____ Total Minutes: _____

S: Pain Level: ______/10, Type: _____________________________






AT = Aquatic Therapy; CP = Cold Pack; CTX = Cervical Traction; ES = Electrical Stimulation; E = Evaluation; F = Fluidotherapy; GT = Gait Training; HP = Hot Pack; I = Iontophoresis; MT = Manual Therapy; MS = Massage; P = Phonophoresis; PTX = Pelvic Traction; RE = Reevaluation; TA = Therapeutic Activities; TE = Therapeutic Exercise; TI = Therapeutic Instruct; U = Ultrasound; Others: ____________________________________________________

Physical therapy daily notesForm 6

Comments: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________Signature: ___________________



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S: Pain Level: ______/10, Type: _____________________________







S: Pain Level: ______/10, Type: _____________________________







Physical therapy daily notes (cont.)Form 6





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S: Pain Level: ______/10, Type: _____________________________







S: Pain Level: ______/10, Type: _____________________________







Physical therapy daily notes (cont.)Form 6




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Client Name: MR #: Start of Care:

dd/mm

dd/mm

dd/mm

dd/mm

dd/mm

dd/mm


❏ 97110 Therapeutic Exercise

❏ 97116 Gait Training


❏ 97112 neuromuscular Reeducation

❏

❏

Signature Key:

Progress Note:


Physical therapy flow sheetForm 7



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Plan of treatment for outpatient rehabilitationForm 8

PLAN OF TREATMENT FOR OUTPATIENT REHABILITATION(COMPLETE FOR INITIAL CLAIMS ONLY)

1. PATIENT’S LAST NAME FIRST NAME M.I. 2. PROVIDER NO. 3. HICN

4. PROVIDER NAME 5. MEDICAL RECORD NO. (Optional) 6. ONSET DATE 7. SOC. DATE

8. TYPE 9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10.TREATMENT DIAGNOSIS 11. VISITS FROM SOC.■ PT ■ OT ■ SLP ■ CR

■ RT ■ PS ■ SN ■ SW

12. PLAN OF TREATMENT FUNCTIONAL GOALS PLAN

GOALS (Short Term)

OUTCOME (Long Term)

13. SIGNATURE (professional establishing POC including prof. designation) 14. FREQ/DURATION (e.g., 3/Wk. x 4 Wk.)

I CERTIFY THE NEED FOR THESE SERVICES FURNISHED UNDER 17. CERTIFICATIONTHIS PLAN OF TREATMENT AND WHILE UNDER MY CARE ■ N/A

FROM THROUGH N/A15. PHYSICIAN SIGNATURE 16. DATE

18. ON FILE (Print/type physician’s name)

■

20. INITIAL ASSESSMENT (History, medical complications, level of function 19. PRIOR HOSPITALIZATIONat start of care. Reason for referral.)

FROM TO N/A


Form CMS-700-(11-91)

21. FUNCTIONAL LEVEL (End of billing period) PROGRESS REPORT ■ CONTINUE SERVICES OR ■ DC SERVICES

22. SERVICE DATESFROM THROUGH



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Plan of treatment for outpatient rehabilitation (cont.)Form 8

1. Patient’s Name - Enter the patient’s last name, first nameand middle initial as shown on the health insurance Medicarecard.

2. Provider Number - Enter the number issued by Medicare tothe billing provider (i.e., 00–7000).

3. HICN - Enter the patient’s health insurance number as shownon the health insurance Medicare card, certification award,utilization notice, temporary eligibility notice, or as reportedby SSO.

4. Provider Name - Enter the name of the Medicare billingprovider.

5. Medical Record No. - (optional) Enter the patient’s medical/clinical record number used by the billing provider.

6. Onset Date - Enter the date of onset for the patient’s primarymedical diagnosis, if it is a new diagnosis, or the date of themost recent exacerbation of a previous diagnosis. If the exactdate is not known enter 01 for the day (i.e., 120191). Thedate matches occurrence code 11 on the UB-92.

7. SOC (start of care) Date - Enter the date services began atthe billing provider (the date of the first Medicare billable visitwhich remains the same on subsequent claims untildischarge or denial corresponds to occurrence code 35 forPT, 44 for OT, 45 for SLP and 46 for CR on the UB-92).

8. Type - Check the type therapy billed; i.e., physical therapy(PT), occupational therapy (OT), speech-language pathology(SLP), cardiac rehabilitation (CR), respiratory therapy (RT),psychological services (PS), skilled nursing services (SN), orsocial services (SW).

9. Primary Diagnosis - Enter the pertinent written medicaldiagnosis resulting in the therapy disorder and relating to50% or more of effort in the plan of treatment.

10. Treatment Diagnosis - Enter the written treatment diagnosisfor which services are rendered. For example, for PT theprimary medical diagnosis might be Degeneration of CervicalIntervertebral Disc while the PT treatment DX might beFrozen R Shoulder or, for SLP, while CVA might be theprimary medical DX, the treatment DX might be Aphasia.If the same as the primary DX enter SAME.

11. Visits From Start of Care - Enter the cumulative total visits(sessions) completed since services were started at thebilling provider for the diagnosis treated, through the last visiton this bill. (Corresponds to UB-92 value code 50 for PT, 51for OT, 52 for SLP, or 53 for cardiac rehab.)

12. Plan of Treatment/Functional Goals - Enter brief currentplan of treatment goals for the patient for this billing period.Enter the major short-term goals to reach overall long-termoutcome. Enter the major plan of treatment to reach stated

goals and outcome. Estimate time-frames to reach goals,when possible.

13. Signature - Enter the signature (or name) and theprofessional designation of the professional establishing theplan of treatment.

14. Frequency/Duration - Enter the current frequency andduration of your treatment; e.g., 3 times per week for 4 weeksis entered 3/Wk x 4Wk.

15. Physician’s Signature - If the form CMS-700 is used forcertification, the physician enters his/her signature. Ifcertification is required and the form is not being used forcertification, check the ON FILE box in item 18. If thecertification is not required for the type service rendered,check the N/A box.

16. Date - Enter the date of the physician’s signature only if theform is used for certification.

17. Certification - Enter the inclusive dates of the certification,even if the ON FILE box is checked in item 18. Check theN/A box if certification is not required.

18. ON FILE (Means certification signature and date) - Enter thetyped/printed name of the physician who certified the planof treatment that is on file at the billing provider. If certificationis not required for the type of service checked in item 8,type/print the name of the physician who referred or orderedthe service, but do not check the ON FILE box.

19. Prior Hospitalization - Enter the inclusive dates of recenthospitalization (1st to DC day) pertinent to the patient’scurrent plan of treatment. Enter N/A if the hospital stay doesnot relate to the rehabilitation being rendered.

20. Initial Assessment - Enter only current relevant historyfrom records or patient interview. Enter the major functionallimitations stated, if possible, in objective measurable terms.Include only relevant surgical procedures, prior hospitalizationand/or therapy for the same condition. Include only pertinentbaseline tests and measurements from which to judge futureprogress or lack of progress.

21. Functional Level (end of billing period) - Enter the pertinentprogress made and functional levels obtained at the end of thebilling period compared to levels shown on initial assessment.Use objective terminology. Date progress when function canbe consistently performed. When only a few visits have beenmade, enter a note indicating the training/treatment renderedand the patient’s response if there is no change in function.

22. Service Dates - Enter the From and Through dates whichrepresent this billing period (should be monthly). Match theFrom and Through dates in field 6 on the UB-92. DO NOT use00 in the date. Example: 01 08 91 for January 8, 1991.

INSTRUCTIONS FOR COMPLETION OF FORM CMS-700(Enter dates as 6 digits, month, day, year)




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Registrar __________________ Patient Has Rx ________ Needs Ref ______ Date _________

Patient Name ____________________________ Sex F M Status ______ DOB _________

Address ______________________________________ Phone(s) _________________________

City _____________________ State ______ ZIP _________ S.S. # _______________________

Patient’s Employer _______________________________ Phone _________________________

Address _________________________________________________________________________

Emergency Contact _______________________________ Relationship ___________________

Phone ________________________

Physician ___________________________ Phone _______________ Fax __________________

Diagnosis ___________________________________ ICD-9 Code ________________________

Insurance #1 _________________ Contract # _________________ Group # _______________

Address ________________________________________ Phone _________________________

Contact Person __________________________ Benefit Coverage _______________________

Insurance #2 ____________________________ Claim # ________ Group # ________________

Contact Person ________________________________ Benefit Coverage _________________

Address ________________________________________ Phone _________________________

Auto Accident: Yes _____ No ______ Worker’s Compensation: Yes ______ No _______

Injury Date ___________ Claim # ______________ Benefit Coverage ____________________

Contact Person __________________________________ Phone _________________________

Insurance Co. ________________ Address __________________________________________

Policy Holder (if different from pt) ___________________________________________________

S.S. # _______________________ DOB _______________

Misc. ____________________________________________________________________________

Appt Scheduled on ___________________ Appt Date ____________________ Time ______

Therapist ___________________________________________________ PT ______ OT ______

Comments: ______________________________________________________________________

Are you currently receiving home nursing and/or home therapy? Yes _______ No ________

If yes, please specify what type: ____________________________________________________

Rehabilitation therapy registration formForm 9


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Client name: MR #: start of Care:

dd/mm

dd/mm

dd/mm

dd/mm

dd/mm

dd/mm


❏ 92526 Tx of swallowing

❏ 92507 Tx of speech, Etc.


❏ 97532 Development of Cog. skills

❏

Signature Key:

Progress Note:


speech-language pathology flow sheetForm 10



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Patient name: DOB: Date:

Facility name: Facility ID: Facility phone number:

Therapist name:

Number of visits: Number of previous treat-ments:

Date of first visit:

Current and prior abilities

Comprehension

Speech

Expression

Swallowing

Cognition

Clinical goals Functional outcomes

Signature:_________________________________________ Date:_________________________

speech therapy evaluationForm 11


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Therapy checklistForm 12

Patient Name ____________________________ Payer: Medicare Insurance _____________

Review Date: _________ Clinic: ______________________ Reviewer: _________________________

Therapist _______________________________ PT PTA OT _________

2nd Therapist ________________________________ PT PTA OT _________

Patient Evaluation & Plan of Care YES NO N/A or CommentsPhysician referral? Is there a script in the chart? Was diagnosis stated? ICD-9 Medical Diagnosis (comes from MD) Was rehab diagnosis stated? ICD-9 Reason for Rehab (therapist) Is date of injury/onset noted? What happened to prompt referral? CHRONIC Objective tests & measurements? From eval of patient Plan of Care established on Progressive POC FormPLOF stated? Related to ADL activities, “Prior to injury patient could…” Previous medical/rehab history? Pertinent medical & rehab – when, why? CLOF stated – deficits? Results of eval – “following injury patient cannot”Are STG established with time frames? (Not required…policy to include?) Are LTG established with time frames? ( entire episode of care) Plan of Care? Was the initial treatment plan explained to the patient? Input solicited? Rehab potential Excellent Good Fair Poor note thisIs the treatment frequency & duration recommended? e.g. 3x week/4 weeks Modalities/Exercises: TE to increase UE ROM + TA to restore dressing Is the POC signed /dated by the referring physician within 30 days

Differentiate in POC TE, TA, NR etc If POC is not returned signed – is there indication in the communication log to follow-up w/ MD Attendance Record/Log Sheet/Flow Sheet/Superbill YES NO N/AAre charge codes indicated daily + support therapy? Is treatment frequency in accordance with Plan of Care? Check log/flow sheet Does treatment plan match signed certification/Plan of Care? Does log/flow sheet indicate exercises and reps? (TE v. TA)

Daily Encounter Notes on FORM YES NO N/APatient subjective trend noted: better, same worse – TREND? Was the stated necessary treatment received? Was patient reaction and tolerance to treatment noted? Documentation note signed by the treating staff member? Documentation note co-signed by the PT/OT if provided by PTA/COTA Is treatment note dated? Does note reflect activity related to goals? Does note reflect skilled care? Medical necessity? Clinical interpretation Is therapy time indicated: Minutes in timed codes/total minutes Is progression to HEP noted? New exercises introduced, patient participation

Source: Bloomingdale Consulting Group. Used with permission.



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Therapy checklist (cont.)Form 12

Progress Notes/Updated POC (Progress to date -10 visits/30 days) YES NO N/AIs current condition updated? Test and measurements/scores Is the patient’s participation and reaction noted? Look for statement Was frequency stated? Patient attendance Were STG reached and documented? Checked completed? Checks If goals were not reached, is the reason documented? Is progress report signed and dated by therapist? Is the physician referral current and updated? Or signed POC Every 10 visits or 30 days? Match 10 visits to 30 days Updated Plan of Care/Plan recertification – (1 or 2 documents) signed?

Interim progress notes may have been written for MD appointment – they may count for Medicare if prepared properly.Discharge Note YES NO N/ADischarge note – summary of last visits since POC TOTAL summary If goals not reached, state why.

Billing/Therapy Caps YES NO N/ADo codes/units on top bar match minutes? Minutes in timed, total minutes Are modifiers used appropriately? GP, KX -59 (Use for billing check) Qualified for automatic exception? By ICD-9 or complexity? Does documentation support therapy beyond the caps? Look for statement addressing the need for continued therapy – related to the CAPS sheet in chart

Overall ImpressionNeatnessPLOF – CLOF – “gap analysis” – this is why “therapy” Daily notes “trend” logically (4-6 visits)

© Bloomingdale Consulting Group, Inc (1996-2008)


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Patient name ____________________________________

Therapist name __________________________________

Facility name ____________________________________

Date services should end __________________________

________________________________________________________________________Level of functioning prior to therapy services

________________________________________________________________________Treatment plan during therapy services

________________________________________________________________________Goals after treatment

________________________________________________________________________Current medical status

________________________________________________________________________Discharge plan and follow-up plan of care

________________________________________________________________________

Signature_______________________________ Date________________________

Therapy discharge noteForm 13



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Updated plan of progress for outpatient rehabilitationForm 14

UPDATED PLAN OF PROGRESS FOR OUTPATIENT REHABILITATION(Complete for Interim to Discharge Claims. Photocopy of CMS-700 or 701 is required.)

1. PATIENT’S LAST NAME FIRST NAME M.I. 2. PROVIDER NO. 3. HICN

4. PROVIDER NAME 5. MEDICAL RECORD NO. (Optional) 6. ONSET DATE 7. SOC. DATE

8. TYPE 9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10.TREATMENT DIAGNOSIS 11. VISITS FROM SOC.■ PT ■OT ■ SLP ■CR

■ RT ■PS ■ SN ■SW12. FREQ/DURATION (e.g., 3/Wk. x 4 Wk.)

13. CURRENT PLAN UPDATE, FUNCTIONAL GOALS (Specify changes to goals and plan.)

GOALS (Short Term) PLAN

OUTCOME (Long Term)

I HAVE REVIEWED THIS PLAN OF TREATMENT AND 14. RECERTIFICATIONRECERTIFY A CONTINUING NEED FOR SERVICES. ■ N/A ■ DC

FROM THROUGH N/A15. PHYSICIAN’S SIGNATURE 16. DATE 17. ON FILE (Print/type physician’s name)

■18. REASON(S) FOR CONTINUING TREATMENT THIS BILLING PERIOD (Clarify goals and necessity for continued skilled care.)


Form CMS-701(11-91)

22. FUNCTIONAL LEVEL (At end of billing period — Relate your documentation to functional outcomes and list problems still present.)

22. SERVICE DATESFROM THROUGH

19. SIGNATURE (or name of professional, including prof. designation) 20. DATE 21.

■ CONTINUE SERVICES OR ■ DC SERVICES



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Updated plan of progress for outpatient rehabilitation (cont.)Form 14

1. Patient’s Name - Enter the patient’s last name, first name andmiddle initial as shown on the health insurance Medicare card.

2. Provider Number - Enter the number issued by Medicare tothe billing provider (i.e., 00–7000).

3. HICN - Enter the patient’s health insurance number as shownon the health insurance Medicare card, certification award,utilization notice, temporary eligibility notice, or as reportedby SSO.

4. Provider Name - Enter the name of the Medicare billingprovider.

5. Medical Record No. - (optional) Enter the patient’s medical/clinical record number used by the billing provider. (This is anitem which you may enter for your own records.)

6. Onset Date - Enter the date of onset for the patient’s primarymedical diagnosis, if it is a new diagnosis, or the date of themost recent exacerbation of a previous diagnosis. If the exactdate is not known enter 01 for the day (i.e., 120191). The datematches occurrence code 11 on the UB-92.

7. SOC (start of care) Date - Enter the date services began atthe billing provider (the date of the first Medicare billable visitwhich remains the same on subsequent claims untildischarge or denial corresponds to occurrence code 35 for PT,44 for OT, 45 for SLP and 46 for CR on the UB-92).

8. Type - Check the type therapy billed; i.e., physical therapy(PT), occupational therapy (OT), speech-language pathology(SLP), cardiac rehabilitation (CR), respiratory therapy (RT),psychological services (PS), skilled nursing services (SN), orsocial services (SW).

9. Primary Diagnosis - Enter the pertinent written medicaldiagnosis resulting in the therapy disorder and relating to 50%or more of effort in the plan of treatment.

10. Treatment Diagnosis - Enter the written treatment diagnosisfor which services are rendered. For example, for PT theprimary medical diagnosis might be Degeneration of CervicalIntervertebral Disc while the PT treatment DX might be FrozenR Shoulder or, for SLP, while CVA might be the primarymedical DX, the treatment DX might be Aphasia.If the same as the primary DX enter SAMPLE.

11. Visits From Start of Care - Enter the cumulative total visits(sessions) completed since services were started at the billingprovider for the diagnosis treated, through the last visit on thisbill. (Corresponds to UB-92 value code 50 for PT, 51 for OT,52 for SLP, or 53 for cardiac rehab.)

12. Current Frequency/Duration - Enter the current frequencyand duration of your treatment; e.g., 3 times per week for 4weeks is entered 3/Wk x 4Wk.

13. Current Plan Update, Functional Goals - Enter the currentplan of treatment goals for the patient for this billing period. (Ifthe same as shown on the CMS-700 or previous 701 enter“same”.) Enter the short-term goals to reach overall long-termoutcome. Justify intensity if appropriate. Estimate time-framesto meet goals, when possible.

14. Recertification - Enter the inclusive dates when recertificationis required, even if the ON FILE box is checked in item 17.Check the N/A box if recertification is not required for the typeof service rendered.

15. Physician’s Signature - If the form CMS-701 is used forrecertification, the physician enters his/her signature. Ifrecertification is not required for the type of service rendered,check N/A box. If the form CMS-701 is not being used forrecertification, check the ON FILE box - item 17. If dischargeis ordered, check DC box.

16. Date - Enter the date of the physician’s signature only if theform is used for recertification.

17. On File (Means certification signature and date) - Enter thetyped/printed name of the physician who certified the plan oftreatment that is on file at the billing provider. If recertification isnot required for the type of service checked in item 8, type/printthe name of the physician who referred or ordered the service,but do not check the ON FILE box.

18. Reason(s) For Continuing Treatment This Billing Period -Enter the major reasons why the patient needs to continueskilled rehabilitation for this billing period (e.g., briefly statethe patient’s need for specific functional improvement, skilledtraining, reduction in complication or improvement in safety andhow long you believe this will take, if possible or state yourreasons for recommending discontinuance). Complete by therehab specialist prior to physician’s recertification.

19. Signature - Enter the signature (or name) and the professionaldesignation of the individual justifying or recommending needfor care (or discontinuance) for this billing period.

20. Date - Enter the date of the rehabilitation professional’ssignature.

21. Check the box if services are continuing or discontinuing at endof this billing period.

22. Functional Level (end of billing period) - Enter the pertinentprogress made through the end of this billing period. Useobjective terminology. Compare progress made to that shownon the previous CMS-701, item 22, or the CMS-700, items 20and 21. Date progress when function can be consistentlyperformed or when meaningful functional improvement is madeor when significant regression in function occurs. Yourintermediary reviews this progress compared to that on theprior CMS-701 or 700 to determine coverage for this billingperiod. Send a photocopy of the form covering the previousbilling period.

23. Service Dates - Enter the From and Through dates whichrepresent this billing period (should be monthly). Match theFrom and Through dates in field 6 on the UB-92. DO NOT use00 in the date. Example: 01 08 91 for January 8, 1991.

INSTRUCTIONS FOR COMPLETION OF FORM CMS-701(Enter dates as 6 digits, month, day, year)


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