Doctor, Do You Have a Plan?
One of Medicare’s documentation requirements, (as well as other managed care providers) is to have a written treatment plan in the patient’s file. Just documenting the frequency of a patient’s visits is not a sufficient treatment plan. A treatment plan has to show medical necessity for care. Medicare has three required elements for a well-documented treatment plan. These three elements include 1. Recommended level of care, 2. Specific treatment goals and 3. Objective measures to evaluate treatment effectiveness.
The “Recommended level of care” is the duration and frequency of visits. This is the part of the treatment plan that most doctors are familiar with. Not only is it important for the doctor to document how long and how often he/she plans to treat the patient, but it is also important to document the re-exam date. Other important information that should be documented is the types of services the doctor will be performing to treat the patient and why he/she is performing each service.
The “Specific Treatment Goals” describes the doctor’s short term and long term treatment goals for the patient. Treatment goals should be objective and discuss how a patient’s treatment will improve his/hers functions in regards to activities of daily living (ADL’s). Many doctors find it difficult to list specific goals because they fail to identify any loss of function that the patient may have. Medicare states that the patient must have a significant health problem in the form of a neuromuscular condition necessitating treatment, and the manipulation services rendered must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectations of recovery or improvement of function. (1) A goal of “reducing the patient’s pain” is not specific enough to show medical necessity for treatment. The use of outcome assessment questionnaires such as the Revised Oswestery, the Triple Visual Analog Scale or the Low Back Pain Disability Questionnaire provide a doctor with objective information about a patient’s loss of function as it relates to their ADL’s. Information obtained in the outcome assessment questionnaires can be used to develop patient treatment goals and measure functional improvement. For more information on outcome assessment questionnaires refer to my article in the ICS newsletter issue 77, July 2009. I also recommend Dr. Steve Yeoman’s book “The Clinical Application of Outcome Assessment.”
The third element of a well-documented treatment plan “Objective Measures to Evaluate Treatment Effectiveness” can be achieved by using outcome assessment questionnaires. Even though it is important to have a subjective complaint and subjective improvement from the patient it is not enough to justify care. A doctor must also show objective improvement. There are no specific requirements by Medicare on how often a doctor should have a patient repeat outcome questionnaires, but re-administering a questionnaire after two weeks of treatment helps show objective findings that the current course of treatment is effective in treating the patient’s loss of function. After two weeks of care if the patient is showing objective improvement, then the doctor should continue with the current treatment plan. If the patient is not improving then there needs to be a change the patient’s treatment. After an additional two weeks of treatment under the new treatment plan, if there is still no objective or functional improvement, it is recommended that the doctor refer the patient to another appropriate health care provider or order an additional diagnostic test.
The outcome questionnaire should also be repeated at the patient’s re-examination (approximately four weeks into care). If the patient is continuing to show objective and functional improvement upon re-examination then the doctor should update the patient’s treatment plan. Once the patient has reached maximum medical improvement or there is no change in the patient’s condition from one re-exam to the next then the patient should be released from active care.
A treatment plan provides Medicare and other third-party payers the medical necessity needed to justify a patient’s need for care. Without a written treatment plan Medicare reviewers as well as other managed care reviewers could deem your care medically unnecessary and require a refund of money that has been paid. Last year, the OIG revealed that for every dollar they spend in a healthcare audit, they recoup $17. The OIG is not just focused on the chiropractic profession but in their May 2009 report titled Inappropriate Medicare Payments for Chiropractic Services, the OIG stated that documentation of treatment plans was insufficient and that only 11% of chiropractors are submitting treatment plans that are acceptable to Medicare. With Medicare and the OIG increasing audits to decrease fraud, waste and abuse it is important to have good documented notes to justify care.
- Medicare Benefit Policy Manual, Chapter 15, Section 240.1.3