Quiz Course: Documentation for SNF Therapy Professionals – Medicare Rules and How-To’s for Part A & B

1. Question

Multiple rule-sets guide therapy documentation in the SNF, including State Practice Acts, Medicare Part A, Medicare Part B and Non-Medicare payors. When Medicare rules and State Practice Act rules contradict each other, which rule set is the priority to be followed?

Medicare
State Practice Act
Whichever rule set (State Practice Act or Medicare) is more stringent.

2. Question

Why is therapy documentation important?

We need to support our therapy practice and prove that we are following LTC regulations (for OBRA '87)
We need to provide adequate information in order to receive payment for our services.
We need to protect ourselves professionally, as well as protect our residents by documenting what did or did not occur.
All of the above

3. Question

The Medicare Part A and Medicare Part B documentation rules are the same in terms of frequency, content and which therapy professionals can complete each document.

True
False

4. Question

The documentation rules for Medicare Part A can be found in Chapter _____ of the Medicare Manual; Medicare Part B rules can be found in Chapter _____.

Chapter 1; Chapter 2
Chapter 5; Chapter 6
Chapter 15; Chapter 8
Chapter 8; Chapter 15

5. Question

Both Medicare Part A and Medicare Part B require daily therapy documentation to outline the skilled services provided.

True
False

6. Question

What is the difference in purpose between a daily treatment encounter note and a progress report?

A daily treatment note justifies medical necessity and a progress report updates goals
A daily treatment note creates a record of skilled treatment activity and time spent with the resident; A progress report justifies medical necessity of continued treatment
Both the daily note and progress report have the same purpose of proving skilled care

7. Question

Medicare Part B requires a clinician [ PT, OT or SLP] to write a Progress Report.

Medicare Part A does not address this in Chapter 8. However, the main reason that assistants [PTA, C/OTA] should not write Medicare Part A Progress Reports is:

Assistants don't write thorough notes
Assistants are expected to have higher productivity and when they write notes their productivity drops
Medicare Part A states that they will pay for services if the skills of the therapist are necessary. Having assistants complete the document that justifies medically necessity may compromise payment as Medicare may deem the services not necessary if the clinician is not heavily involved in the care of the resident.

8. Question

Therapy documentation should clearly identify WHY the service is skilled and HOW the service is reasonable and necessary in frequency, duration and content.

True
False

9. Question

Skilled therapy includes providing both Direct Care and Indirect Care.

Examples of Indirect Care include which of the following:

Management and Evaluation of the overall plan of care
Observation and Assessment of a resident's condition when there is a likelihood of change
Teaching and Training activities
All of the above

10. Question

The Medicare Manual states that the following terminology found in therapy documentation may be cause for automatic denial of payment:

"Continue plan of care"
"Tolerated well"
"Continue treatment as above"
All of the above statements may cause denial