CMS Documentation Guidelines: The Who, What and Why

CMS Documentation Guidelines:  The Who, What and Why

By Rex Crosby, OTR/L

This text-based course is a written transcript of the event, “CMS Documentation Guidelines: The Who, What and Why”, that was presented by Rex Crosby, OTR/L on December 5, 2011.

Introduction

  Today, we are going to talk about the CMS (Centers for Medicare and Medicaid Services) documentation guidelines.  Usually the first time anyone speaks to a therapist about documentation guidelines (what is needed in the documentation) is at the end of their clinical affiliation.  The last thing that my Level 2 clinical instructor told me was, "Good luck with your career.  Work on your documentation."   Throughout my career, I really never had anyone sit down with me; regardless of the venue where I was practicing, and discuss what it was exactly that I needed to have in my documentation.  What was it that Medicare was requiring of me, or any of the other payer sources?  So, today, what we are going to talk about is documentation.  We are going to describe the importance of clinical documentation,  list the conditions of coverage for therapy services, talk about what has to be met for payment of services, define what constitutes reasonable and necessary therapy services (which is the heart of what the documentation is to convey), and finally identify the stages of the Medicare appeals process.

Medicare

What we are finding nowadays in the healthcare industry is that Medicare is having difficulties having enough money in their trust fund.   More and more funds are being taken out for our beneficiaries causing the Medicare trust fund to not have a neutral budget.   There is more going out in paid claims than what is actually being replenished under the current rules.  What we are now seeing, as a result, is that Medicare has a significant number of auditors out there trying to deny claims.

 Now, typically, when I speak to therapists, I'll ask them, "If we were to make a list of what is the most important item that we do as healthcare professionals," usually the number one answer is patient care.   I think we can all agree that patient care should always come first with what we do.   I already know that on the list we will have HIPAA compliance, confidentiality, patient safety, education, et cetera, et cetera.

But, when I ask, "Where does documentation fit into our priorities?" Sometimes I  hear, "Well, it's number two," or “it's number three”, or it might even be number ten, as some therapists tend to look at documentation as that dirty little word.   That thing that we have to do every week; it's just a requirement. We really do not understand the significance of that.  My experience shows, especially having to deal with the Medicare appeals process and denial management, is that documentation is not number two or three or ten.  Documentation is 1-a, because without our clinical documentation supporting what we are doing and the patient care that we provide, regardless of the outcomes, is not reimbursable by Medicare or other payor sources.  Due its importance, I like to spend a lot of time with the therapists discussing how we are documenting, what we are documenting, and trying to convey an understanding of what exactly it is that Medicare and our other payer sources are looking for.

Today, we are going to spend time talking about what Medicare is looking for because typically other payer sources follow Medicare guidelines.