Rule 23-213-1.11 - DocumentationA. Physical therapy provider records must document and maintain records in accordance with requirements set forth in Miss. Admin. Code Part 200, Rule 1.3. B. Required documentation by a servicing physical therapy provider includes, but is not limited to, the following: 1. Beneficiary demographic information, 2. A copy of the Certificate of Medical Necessity for Initial Referral/Orders completed by the prescribing provider, 3. Signed consent for treatment, 4. Original copies of all Outpatient Therapy Evaluation/Re-Evaluation specific to the therapy ordered, 5. The original copies of all Outpatient Therapy Plan of Care specific to the therapy requested, 6. The original copies of all tests performed or a list of all tests performed, test results, and the written evaluation reports, 7. Treatment log if treatment times are not documented in the progress notes including all requirements for timed codes as follows: a) The Division of Medicaid defines timed codes as procedure codes that reference a time per unit. b) The Division of Medicaid covers units of timed codes based upon the total time actually spent in the delivery of the service. c) The Division of Medicaid considers the following activities as not part of the total treatment time: 1) Pre and post-delivery of services, 2) Time the beneficiary spends not being treated, and 3) Time waiting for equipment or for treatment to begin. d) The Division of Medicaid defines untimed codes as procedure codes that are not defined by a specific time frame. e) The Division of Medicaid does not require documentation of the treatment time for untimed codes. f) The Division of Medicaid only covers one (1) unit for untimed codes regardless of the amount of time taken to complete the service. 8. Progress notes: a) Must be documented at least weekly, b) Must include: 2) Specific treatment modalities/procedures performed, 3) Beneficiary's response to treatment, 5) Problems interfering with progress, 6) Education/teaching activities and results, 8) Progress toward discharge goals/home program activities, and 9) The signature and title of the therapist providing the service(s). c) If treatment times are documented in the progress notes in lieu of a treatment log, all requirements for timed codes must be met as follows: 1) The Division of Medicaid defines timed codes as procedure codes that reference a time per unit. 2) The Division of Medicaid covers units of timed codes based upon the total time actually spent in the delivery of the service. 3) The Division of Medicaid considers the following activities as not part of the total treatment time: (a) Pre and post-delivery of services., (b) Time the beneficiary spends not being treated, and (c) Time waiting for equipment or for treatment to begin. 4) The Division of Medicaid defines untimed codes as procedure codes that are not defined by a specific time frame. 5) The Division of Medicaid does not require documentation of the treatment time for untimed codes. 6) The Division of Medicaid only covers one (1) unit for untimed codes regardless of the amount of time taken to complete the service. 9. Discharge summary, if applicable, and 10. A copy of the completed prior approval authorization form with prior approval, if applicable. C. Required documentation by prescribing providers must include, but is not limited to, the following: 2. Beneficiary demographic information, 3. Signed consent for treatment, 4. Medical history/chief complaint, 6. Specific name/type of all diagnostic studies and results/findings of the studies, 7. Treatment rendered and response to treatment, 8. Medications prescribed including name, strength, dosage, and route, 9. Orders that are signed and dated for all medications, treatments, and procedures rendered, 10. Discharge planning and beneficiary instructions, 11. Copy of the Certificate of Medical Necessity for Initial Referral/Orders, 12. Evidence that the beneficiary was seen face-to-face and evaluated/re-evaluated every six (6) months at a minimum. D. In addition, the prescribing provider must retain copies of the rendering provider's/therapist's documentation as follows: 1. Initial therapy evaluation and all re-evaluations, 2. Initial plan of care and all revisions, 3. Written evaluation reports for all tests, and 4. Discharge summary, if applicable. 23 Miss. Code. R. 213-1.11
42 C.F.R. §§ 422.504, 485.713; Miss. Code Ann. §§ 43-13-117, 43-13-121.