HCPro, Inc.,hcmarketplace.com/media/browse/6263_browse.pdf · Form 4: Occupational therapy flow...
Transcript of HCPro, Inc.,hcmarketplace.com/media/browse/6263_browse.pdf · Form 4: Occupational therapy flow...
Essential Forms forTherapists
HCPro, Inc., with Kate Brewer, PT, MBA, GCS
Essential Forms
forTherapists
Essential Forms for Therapists is published by HCPro, Inc.
Copyright © 2008 HCPro, Inc.
All rights reserved. Printed in the United States of America. 5 4 3 2 1
ISBN 978-1-60146-158-2
No part of this publication may be reproduced, in any form or by any means, without prior
written consent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please no-
tify us immediately if you have received an unauthorized copy.
HCPro, Inc., provides information resources for the healthcare industry.
HCPro, Inc., is not affiliated in any way with The Joint Commission, which owns the JCAHO
and Joint Commission trademarks.
Kate Brewer, PT, MBA, GCS, Reviewer Sada Preisch, Proofreader
Adrienne Trivers, Managing Editor Darren Kelly, Books Production Supervisor
Elizabeth Petersen, Executive Editor Susan Darbyshire, Art Director
Emily Sheahan, Group Publisher Patrick Campagnone, Cover Designer
Janell Lukac, Layout Artist Claire Cloutier, Production Manager
Anne Kilgore, Layout Artist Jean St. Pierre, Director of Operations
Audrey Doyle, Copyeditor
Advice given is general. Readers should consult professional counsel for specific legal, ethical,
or clinical questions.
Arrangements can be made for quantity discounts. For more information, contact:
HCPro, Inc.
P.O. Box 1168
Marblehead, MA 01945
Telephone: 800/650-6787 or 781/639-1872
Fax: 781/639-2982
E-mail: [email protected]
Visit HCPro at its World Wide Web sites:
www.hcpro.com and www.hcmarketplace.com
3/200821395
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
section 1
�
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
Essential Forms for Therapists
Therapy Documentation Forms
�
inpatient rehab patient assessment instrument (cont.)
INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
Form CMS-10036 (01/06) 2
Form 1
Essential Forms for Therapists
section 1
�
inpatient rehab patient assessment instrument (cont.)
INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENT
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
Form CMS-10036 (01/06) 3
Form 1
Source: The Centers for Medicare & Medicaid Services
Essential Forms for Therapists
Therapy Documentation Forms
�
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.
Essential Forms for Therapists
section 1
�
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
Essential Forms for Therapists
Therapy Documentation Forms
�
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
Essential Forms for Therapists
section 1
�
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
Essential Forms for Therapists
Therapy Documentation Forms
�
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: _____________________________
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
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: ___________________
Comments: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________Signature: ___________________
Essential Forms for Therapists
section 1
�0
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: _____________________________
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
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 notes (cont.)Form 6
Comments: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________Signature: ___________________
Comments: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________Signature: ___________________
Essential Forms for Therapists
Therapy Documentation Forms
��
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: _____________________________
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
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 notes (cont.)Form 6
Comments: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________Signature: ___________________
Comments: _______________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________Signature: ___________________
Essential Forms for Therapists
section 1
��
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
❏ 97116 Gait Training
❏ 97530 Therapeutic Activities
❏ 97112 neuromuscular Reeducation
❏
❏
Signature Key:
Progress Note:
Source: Progressive Rehab Solutions. Used with permission.
Physical therapy flow sheetForm 7
Essential Forms for Therapists
Therapy Documentation Forms
��
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
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
Form CMS-700-(11-91)
21. FUNCTIONAL LEVEL (End of billing period) PROGRESS REPORT ■ CONTINUE SERVICES OR ■ DC SERVICES
22. SERVICE DATESFROM THROUGH
Source: The Centers for Medicare & Medicaid Services
Essential Forms for Therapists
section 1
��
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)
Source: The Centers for Medicare & Medicaid Services
Essential Forms for Therapists
Therapy Documentation Forms
��
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
Essential Forms for Therapists
section 1
��
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
❏ 92526 Tx of swallowing
❏ 92507 Tx of speech, Etc.
❏ 97530 Therapeutic Activities
❏ 97532 Development of Cog. skills
❏
Signature Key:
Progress Note:
Source: Progressive Rehab Solutions. Used with permission.
speech-language pathology flow sheetForm 10
Essential Forms for Therapists
Therapy Documentation Forms
��
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
Essential Forms for Therapists
section 1
��
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.
Essential Forms for Therapists
Therapy Documentation Forms
��
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)
Essential Forms for Therapists
section 1
�0
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
Essential Forms for Therapists
Therapy Documentation Forms
��
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.)
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES
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
Source: The Centers for Medicare & Medicaid Services
Essential Forms for Therapists
section 1
��
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)
Source: The Centers for Medicare & Medicaid Services
Name
Title
Organization
Street Address
City State ZIP
Telephone Fax
E-mail Address
Order your copy today!
Title Price Order Code Quantity Total
$
Shipping* $ (see information below)
Sales Tax** $ (see information below)
Grand Total $
*Shipping InformationPlease include applicable shipping. For books under $100, add $10. For books over $100, add $18. For shipping to AK, HI, or PR, add $21.95.
**Tax InformationPlease include applicable sales tax. States that tax products and shipping and handling: CA, CO, CT, FL, GA, IL, IN, KY, LA, MA, MD, ME, MI, MN, MO, NC, NJ, NM, NY, OH, OK, PA, RI, SC, TN, TX, VA, VT, WA, WI, WV.
State that taxes products only: AZ.
BIllInG OPTIOnS:
Bill me Check enclosed (payable to HCPro, Inc.) Bill my facility with PO # ________________
Bill my (3 one): VISA MasterCard AmEx Discover
Signature Account No. Exp. Date
(Required for authorization) (Your credit card bill will reflect a charge from HCPro, Inc.)
© 2008 HCPro, Inc. HCPro, Inc. is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Code: EBKPDF
Order online at www.hcmarketplace.com Or if you prefer: MAIl ThE COMPlETEd OrdEr fOrM TO: HCPro, Inc. P.O. Box 1168, Marblehead, MA 01945
CAll Our CuSTOMEr SErvICE dEPArTMEnT AT: 800/650-6787
fAx ThE COMPlETEd OrdEr fOrM TO: 800/639-8511
E-MAIl: [email protected]
P.O. Box 1168 | Marblehead, MA 01945 | 800/650-6787 | www.hcmarketplace.com
Please fill in the title, price, order code and quantity, and add applicable shipping
and tax. for price and order code, please visit www.hcmarketplace.com. If you
received a special offer or discount source code, please enter it below.
Your order is fully covered by a 30-day, money-back guarantee.
Enter your special Source Code here: