Is it necessary to have time in and time out on clinical notes?

Is it a requirement to have the health insurance claim (HIC) number on the plan of care (POC)?

What terms should be avoided in the progress notes?

What is the timeframe to return medical records when an additional documentation request (ADR) has been received?

Can a recertification be signed by a physician assistant (PA) or advanced registered nurse practitioner (ARNP), in place of a physician?

Can a physical therapist assistant (PTA) provide care for a patient without constant oversight from a physical therapist (PT) for both Part A and B?

A: Yes, it is necessary and FCSO prefers total minutes.

A: No, it is not a requirement.

A: The following are a few examples of terms you should avoid in the progress notes: ‘Doing well’, ‘Improving’, ‘Less pain’, ‘Increased range of motion’, ‘Increased strength’, and ‘Tolerated treatment well’. These do not give an indication of how much progress was made in therapy and are not measurable.

A: The ADR states you have 45-days to submit the medical records; however, we highly recommend you return the records as soon as possible. The fiscal intermediary shared system (FISS) edits are set up to deny claims on the 45th day after the ADR has been created.

A: Yes. The CMS Internet-only Manual (IOM), Publication 100-02, Chapter 15, Section 220.1.3, shows the physician/non-physician practitioner (NPP) can sign certifications.

A. PTAs may not provide evaluation services, make clinical judgments or decisions or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws.

A physical therapist must supervise PTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless state practice requirements are more stringent, in which case state or local requirements must be followed. See specific settings for details. For example, in clinics, rehabilitation agencies, and public health agencies, the Code of Federal Regulations at 42CFR485.713 indicates that when a PTA provides services, either on or off the organization’s premises, those services are supervised by a qualified physical therapist who makes an onsite supervisory visit at least once every 30 days or more frequently if required by state or local laws or regulation.