I had posted a question regarding physicians singing off on PT notes for documentation supporting medical necessity primarily for orthotic devices, mainly custom AFOs. Heres my original post.
Hello dear colleagues,We have been told that Physical Therapy notes are valid for clinical documentation for Medicare as long as the ordering physician signs off on those clinical notes. We have recently had 2 Performant RAC audits for Medicare beneficiaries, one from 2019 and one from 2020, that were both reevaluated and denied post payment stating that “the documentation provided did not include medical records for review”, and, that “since documentation from the treating physician was not provided for review, it could not be determined that the beneficiary could not be fit with a prefabricated device; or, there was a need to control the knee, ankle or foot in more than one plane: etc”. And, “although supplier records were provided, it could not be determined if the records corroborate documentation in the physician’s records to support the need for custom fabrication, since documentation from the treating physician was not provided for review.”
We did supply both Orthotist and Physical Therapist clinical notes, and the PT notes were cosigned by the Physician, all prior to providing the services. Are we wrong in assuming that cosigned PT notes are adequate clinical documentation to support the need for a device and for a custom fabricated device, even when specifically addressed in those notes? One patient was in an SNF and the other was seen in an Out Patient Physical Therapy Clinic.
I would appreciate to hear what the O and P community has been doing in these cases. Thank you.
Karl Entenmann, CPO
Preferred / Evergreen PO
The consensus was that
PT notes are also only supportive of physician notes and physician notes must at least show a face to face visit for the underlying issue. Then the physician can sign off on the PT notes. A couple suggested to appeal to the ALJ which we will. Im 70. Should have that ALJ appointment by my 75th birthday.