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laitnessE rmsFo istsparforTheHCPro, Inc.,with Kate Brewer, PT, MBA, GCS

smroFlaitneEsfosr herapistsT

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 1ISBN 978-1-60146-158-2No part of this publication may be reproduced, in any form or by any means, without priorwritten consent of HCPro, Inc., or the Copyright Clearance Center (978/750-8400). Please notify 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 JCAHOand Joint Commission trademarks.Kate Brewer, PT, MBA, GCS, ReviewerSada Preisch, ProofreaderAdrienne Trivers, Managing EditorDarren Kelly, Books Production SupervisorElizabeth Petersen, Executive EditorSusan Darbyshire, Art DirectorEmily Sheahan, Group PublisherPatrick Campagnone, Cover DesignerJanell Lukac, Layout ArtistClaire Cloutier, Production ManagerAnne Kilgore, Layout ArtistJean St. Pierre, Director of OperationsAudrey Doyle, CopyeditorAdvice 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 1168Marblehead, MA 01945Telephone: 800/650-6787 or 781/639-1872Fax: 781/639-2982E-mail: [email protected] HCPro at its World Wide Web sites:www.hcpro.com and www.hcmarketplace.com3/200821395

C o n te n t ss ect i o n 1Therapy Documentation Forms. 1Form 1: Inpatient rehab patient assessment instrument. 2Form 2: MD referral. 5Form 3: Medical necessity documentation form. 6Form 4: Occupational therapy flow sheet. 7Form 5: Physical therapy and occupational therapy evaluation. 8Form 6: Physical therapy daily notes. 9Form 7: Physical therapy flow sheet. 12Form 8: Plan of treatment for outpatient rehabilitation. 13Form 9: Rehabilitation therapy registration form. 15Form 10: Speech-language pathology flow sheet. 16Form 11: Speech therapy evaluation. 17Form 12: Therapy checklist. 18Form 13: Therapy discharge note. 20Form 14: Updated plan of progress for outpatient rehabilitation. 21s ect i o n 2Managed Care. 23Form 15: Managed care competitor analysis. 24Form 16: Managed care market analysis. 25Form 17: Managed care network analysis. 26Form 18: Managed care rehabilitation quotient. 27Form 19: Therapy progress report for managed care plans. 29s ect i o n 3Personnel Management & Human Resources. 31Form 20: Goal setting worksheet. 32Form 21: Insurance labels. 33Form 22: Intercommittee action request. 34Form 23: Job description template. 35Form 24: Meeting attendance record. 38Form 25: Meeting checklist. 39Form 26: Meeting minutes. 41Form 27: New manager foundation knowledge/skills assessment. 42Form 28: Patient satisfaction survey. 43Essential Forms for Therapistsiii

ContentsForm 29: Performance review template. 44Form 30: Professional development. 60Form 31: Professional development career path. 61Form 32: Therapist credentialing profile. 62Form 33: I-9, Employment eligibility verification. 64Form 34: W-9, Request for taxpayer ID number and certification. 68s ect i o n 4Essential CMS Forms. 73Form 35: Advance beneficiary notice – general. 74Form 36: Advance beneficiary notice – laboratory. 75Form 37: CORF facility request for certification to participate in Medicare program. 76Form 38: CORF survey report. 78Form 39: Fire safety report. 93Form 40: Fire/smoke zone evaluation worksheet for healthcare facilities. 108Form 41: Medicare reconsideration request form. 113Form 42: Medicare redetermination request form. 114Form 43: Notice of denial of medical coverage. 115Form 44: Notice of denial of payment. 117Form 45: Notice of exclusions from Medicare benefits. 119Form 46: Notice of Medicare noncoverage. 120Form 47: Outpatient therapy survey report. 121Form 48: Patient request for medical payment – English version. 136Form 49: Patient request for medical payment – Spanish version. 138Form 50: Provider tie-in notice. 140Form 51: Rehab hospital criteria worksheet. 141Form 52: Rehab unit criteria worksheet. 145Form 53: Request for certification in Medicare and Medicaid. 151Form 54: Request for Medicare hearing by an administrative law judge. 153Form 55: Skilled nursing facility ABN. 155Form 56: Transfer of appeal rights. 156ivEssential Forms for Therapists

CD-ROM contentsAdditionally on the CD-ROM you will find the following forms:Sect i o n 5Job DescriptionsForm 57: Accounting managerForm 58: Accounts payable assistantForm 59: Accounts payable managerForm 60: Administrative assistantForm 61: Billing assistantForm 62: Coder – medical recordsForm 63: Coding supervisorForm 64: Director, patient financial servicesForm 65: Human resources assistantForm 66: Human resources coordinatorForm 67: Job description templateForm 68: Medicare billing specialistForm 69: Occupational therapistForm 70: Occupational therapist, no degreeForm 71: Occupational therapy assistantForm 72: Outpatient rehabilitation directorForm 73: Payroll assistantForm 74: Payroll clerkForm 75: Physical therapistForm 76: Physical therapist, no degreeForm 77: Physical therapy assistantForm 78: Receptionist – HR assistantForm 79: Rehab manager, VNAForm 80: Risk managerForm 81: SecretaryForm 82: Senior rehab therapistForm 83: Speech-language therapistForm 84: Speech therapistForm 85: Third-party payerEssential Forms for Therapists

CD-ROM contentsSect i o n 6Performance ReviewsForm 86: Accounting managerForm 87: Accounts payable assistantForm 88: Accounts payable managerForm 89: Administrative assistantForm 90: Billing assistantForm 91: Coder – medical recordsForm 92: Coding supervisorForm 93: Director, patient financial servicesForm 94: Human resources assistantForm 95: Human resources coordinatorForm 96: Medicare billing specialistForm 97: Occupational therapistForm 98: Occupational therapist, no degreeForm 99: Occupational therapy assistantForm 100: Outpatient rehabilitation directorForm 101: Payroll assistantForm 102: Payroll clerkForm 103: Performance review templateForm 104: Physical therapistForm 105: Physical therapist, no degreeForm 106: Physical therapy assistantForm 107: Receptionist – HR assistantForm 108: Rehab manager, VNAForm 109: Risk managerForm 110: SecretaryForm 111: Senior rehab therapistForm 112: Speech-language therapistForm 113: Speech therapistForm 114: Third-party payerviEssential Forms for Therapists

s ect i o n 1Therapy DocumentationFormsIn this section, you will find the following forms:Form 1: Inpatient rehab patient assessment instrumentForm 2: MD ReferralForm 3: Medical necessity documentation formForm 4: Occupational therapy flow sheetForm 5: Physical therapy and occupational therapy evaluationForm 6: Physical therapy daily notesForm 7: Physical therapy flow sheetForm 8: Plan of treatment for outpatient rehabilitationForm 9: Rehabilitation therapy registration formForm 10: Speech-language pathology flow sheetForm 11: Speech therapy evaluationForm 12: Therapy checklistForm 13: Therapy dischargeForm 14: Updated plan of progress for outpatient rehabEssential Forms for Therapists

Section 1Form 1DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESInpatient rehab patient assessment instrumentForm ApprovedOMB No. 0938-0842INPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENTForm CMS-10036 (01/06) Essential Forms for Therapists1

Therapy Documentation FormsForm 1Inpatient rehab patient assessment instrument (cont.)DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESINPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENTForm CMS-10036 (01/06)2Essential Forms for Therapists

Section 1Form 1Inpatient rehab patient assessment instrument (cont.)DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESINPATIENT REHABILITATION FACILITY – PATIENT ASSESSMENT INSTRUMENTForm CMS-10036 (01/06)Source: The Centers for Medicare & Medicaid Services Essential Forms for Therapists3

Therapy Documentation FormsMD referralForm 2Professional ReferralFor Medical ConsultationBusiness NameAddress:Phone: ( )FAX: ( )INSERTLOGODear (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/ /DateReferring 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 tovia 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 timePhysician’s signature/ /DateIn addition to traditional outpatient orthopedic physical therapy, provides the following specialtyevaluations/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 ofyour patients**Source: Lynn Steffes, Steffes & Associates Consulting Group, LLC. Used with permission.Essential Forms for Therapists

Section 1Form 3Medical necessity documentation formTherapist 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: Essential Forms for Therapists

Therapy Documentation FormsOccupational therapy flow sheetForm 4Client Name:Start of Care:MR #:Plan of b 97110 Therapeutic Exercise 97535 ADL Retraining 97530 Therapeutic Activities 97112 NeuromuscularReeducation Signature Key:Progress Note:Source: Progressive Rehab Solutions. Used with permission.Essential Forms for Therapists

Section 1Physical therapy and occupational therapy evaluationForm 5Patient name:DOB:Date:Facility name:Facility ID:Facility phone number:Number of previous treatments:Date of first visit:Therapist name:Number of visits:Previous functional status and abilitiesStrengthRange of motionPain urrent functional status and abilitiesPain ange of motionFunctional outcomesSignature: Date: Essential Forms for Therapists

Therapy Documentation FormsPhysical therapy daily notesForm 6Pt. Name: MR #: Account #:Tx #: Date: Minutes in timed codes: Charges: Total Minutes:S:Pain Level: /10, Type:Location: Worse Improving See Comments No ChangeO: Treatment:Modalities:Therapeutic Exercise:Therapeutic Activities:Manual Therapy:Other: Flow Sheet Flow Sheet Flow Sheet Flow Sheet Flow Sheet Comments Comments Comments Comments CommentsA. Progressing toward functional goals: Yes No CommentsSkin normal appearance after modalities: Yes No CommentsP. Continue Current Tx Tx Changes See CommentsComments:Signature:Tx #: Date: Minutes in timed codes: Charges: Total Minutes:S:Pain Level: /10, Type:Location: No Change Worse Improving See CommentsO: Treatment:Modalities:Therapeutic Exercise:Therapeutic Activities:Manual Therapy:Other: Flow Sheet Flow Sheet Flow Sheet Flow Sheet Flow Sheet Comments Comments Comments Comments CommentsA. Progressing toward functional goals: Yes No CommentsSkin normal appearance after modalities: Yes No CommentsP. Continue Current Tx Tx Changes See CommentsComments:Signature: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 TherapeuticInstruct; U Ultrasound; Others:Essential Forms for Therapists

Section 1Physical therapy daily notes (cont.)Form 6Tx #: Date: Minutes in timed codes: Charges: Total Minutes:S:Pain Level: /10, Type:Location: No Change Worse Improving See CommentsO: Treatment:Modalities:Therapeutic Exercise:Therapeutic Activities:Manual Therapy:Other: Flow Sheet Flow Sheet Flow Sheet Flow Sheet Flow Sheet Comments Comments Comments Comments CommentsA. Progressing toward functional goals: Yes No CommentsSkin normal appearance after modalities: Yes No CommentsP. Continue Current Tx Tx Changes See CommentsComments:Signature:Tx #: Date: Minutes in timed codes: Charges: Total Minutes:S:Pain Level: /10, Type:Location: No Change Worse Improving See CommentsO: Treatment:Modalities:Therapeutic Exercise:Therapeutic Activities:Manual Therapy:Other: Flow Sheet Flow Sheet Flow Sheet Flow Sheet Flow Sheet Comments Comments Comments Comments CommentsA. Progressing toward functional goals: Yes No CommentsSkin normal appearance after modalities: Yes No CommentsP. Continue Current Tx Tx Changes See CommentsComments:Signature: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 TherapeuticInstruct; U Ultrasound; Others:10Essential Forms for Therapists

Therapy Documentation FormsPhysical therapy daily notes (cont.)Form 6Tx #: Date: Minutes in timed codes: Charges: Total Minutes:S:Pain Level: /10, Type:Location: No Change Worse Improving See CommentsO: Treatment:Modalities:Therapeutic Exercise:Therapeutic Activities:Manual Therapy:Other: Flow Sheet Flow Sheet Flow Sheet Flow Sheet Flow Sheet Comments Comments Comments Comments CommentsA. Progressing toward functional goals: Yes No CommentsSkin normal appearance after modalities: Yes No CommentsP. Continue Current Tx Tx Changes See CommentsComments:Signature:Tx #: Date: Minutes in timed codes: Charges: Total Minutes:S:Pain Level: /10, Type:Location: No Change Worse Improving See CommentsO: Treatment:Modalities:Therapeutic Exercise:Therapeutic Activities:Manual Therapy:Other: Flow Sheet Flow Sheet Flow Sheet Flow Sheet Flow Sheet Comments Comments Comments Comments CommentsA. Progressing toward functional goals: Yes No CommentsSkin normal appearance after modalities: Yes No CommentsP. Continue Current Tx Tx Changes See CommentsComments:Signature: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 TherapeuticInstruct; U Ultrasound; Others:Essential Forms for Therapists11

Section 1Physical therapy flow sheetForm 7Client Name:MR #:Plan of TreatmentStart of Care:dd/mmdd/mmdd/mmdd/mmdd/mmdd/mmkbkbkbkbkbkb 97110 Therapeutic Exercise 97116 Gait Training 97530 Therapeutic Activities 97112 NeuromuscularReeducation Signature Key:Progress Note:Source: Progressive Rehab Solutions. Used with permission.12Essential Forms for Therapists

Therapy Documentation FormsPlan of treatment for outpatient rehabilitationForm 8DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESPLAN OF TREATMENT FOR OUTPATIENT REHABILITATION(COMPLETE FOR INITIAL CLAIMS ONLY)1. PATIENT’S LAST NAMEFIRST NAME4. PROVIDER NAME5. MEDICAL RECORD NO. (Optional)8. TYPE PT OT RT PS SLPSN CRM.I.2. PROVIDER NO.3. HICN6. ONSET DATE7. SOC. DATE9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10.TREATMENT DIAGNOSIS 11. VISITS FROM SOC.SW12. PLAN OF TREATMENT FUNCTIONAL GOALSPLANGOALS (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 UNDERTHIS PLAN OF TREATMENT AND WHILE UNDER MY CARE N/A17. CERTIFICATION15. PHYSICIAN SIGNATURE16. DATEFROMTHROUGHN/A18. ON FILE (Print/type physician’s name) 20. INITIAL ASSESSMENT (History, medical complications, level of functionat start of care. Reason for referral.)19. PRIOR HOSPITALIZATION21. FUNCTIONAL LEVEL (End of billing period) PROGRESS REPORT Form CMS-700-(11-91)FROMTOCONTINUE SERVICES OR22. SERVICE DATESFROMN/A DC SERVICESTHROUGHSource: The Centers for Medicare & Medicaid ServicesEssential Forms for Therapists13

Section 1Plan of treatment for outpatient rehabilitation (cont.)Form 8INSTRUCTIONS FOR COMPLETION OF FORM CMS-700(Enter dates as 6 digits, month, day, year)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 statedgoals 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.Source: The Centers for Medicare & Medicaid Services14Essential Forms for Therapists

Therapy Documentation FormsForm 9Rehabilitation therapy registration formRegistrar Patient Has Rx Needs Ref DatePatient Name Sex F MStatus DOBAddress Phone(s)City State ZIP S.S. #Patient’s Employer PhoneAddressEmergency Contact RelationshipPhonePhysician Phone FaxDiagnosis Icd-9 CodeInsurance #1 Contract # Group #Address PhoneContact Person Benefit CoverageInsurance #2 Claim # Group #Contact Person Benefit CoverageAddress PhoneAuto Accident: Yes NoWorker’s Compensation: Yes NoInjury Date Claim # Benefit CoverageContact Person PhoneInsurance Co. AddressPolicy Holder (if different from pt)S.S. # DobMisc.Appt Scheduled on Appt Date TimeTherapist Pt OtComments:Are you currently receiving home nursing and/or home therapy? Yes NoIf yes, please specify what type:Essential Forms for Therapists15

Section 1Speech-language pathology flow sheetForm 10Client Name:MR #:Plan of TreatmentStart of Care:dd/mmdd/mmdd/mmdd/mmdd/mmdd/mmkbkbkbkbkbkb 92526 Tx of Swallowing 92507 Tx of Speech, Etc. 97530 Therapeutic Activities 97532 Development ofCog. Skills Signature Key:Progress Note:Source: Progressive Rehab Solutions. Used with permission.16Essential Forms for Therapists

Therapy Documentation FormsSpeech therapy evaluationForm 11Patient name:DOB:Date:Facility name:Facility ID:Facility phone number:Number of previous treatments:Date of first visit:Therapist name:Number of visits:Current and prior gnitionClinical goalsFunctional outcomesSignature: Date:Essential Forms for Therapists17

Section 1Therapy checklistForm 12Patient NameReview Date:Payer:MedicareInsuranceClinic: Reviewer:TherapistPTPTAOT2nd TherapistPTPTAOTPatient Evaluation & Plan of CarePhysician referral? Is there a script in the chart?Was diagnos

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 n