Medicare Documentation: Complex Scenarios

The following scenarios describe how to approach treatment for Medicare patients, including when to create new cases or discharge existing cases.

Scenario 1: Patient stops coming to therapy but returns within 60 days, and they want you to treat them for the same diagnosis.

If a patient stops attending therapy mid-treatment but returns within two months (60 days) to continue treatment for the same issue, you can simply resume treating and documenting as if the patient never left in the first place (you do not need to complete a Discharge Summary on the original case).

However, If you have already completed a Quick Discharge note for the patient’s case, we recommend creating a new case to continue treating the patient. As a best practice, cases should not be re-opened to continue documentation once it has been discharged.

What to do in WebPT if you’ve already discharged the patient’s original case

  1. Create a new case for this patient.
  2. Begin a new Initial Examination. If you have the Case Copy Setting turned on for your company, you will be able to automatically populate much of the note’s data with from the patient’s most recently finalized evaluative note in their previous case.

Scenario 2: Patient stops coming to therapy but returns within 60 days, and they want you to treat them for a different diagnosis

If a patient self-discharges and returns to therapy within 60 days to receive treatment for a different complaint, you must discharge the patient’s original case and begin documenting with an Initial Evaluation in a new case.

What to do in WebPT

  1. Ensure the patient has a Quick Discharge note in the original case.
  2. Create a new case for this patient.
  3. Perform an Initial Examination.

Scenario 3: Patient stops attending therapy and returns after 60 days for treatment (for the same or a new diagnosis).

If the patient returns to therapy, simply perform an initial examination and begin documenting as if you were treating a new patient.

What to do in WebPT

  1. Ensure the patient has a Quick Discharge note in the original case.
  2. Create a new case for the patient.
  3. Perform an Initial Examination.

Scenario 4: Patient is receiving treatment from you and he or she presents with a second, unrelated diagnosis.

If a patient is currently being treated by you, and then the patient presents with a prescription for a second, unrelated diagnosis, you have two options:

A) Perform a Re-Examination and add the second diagnosis to the existing case

You can perform a re-examination, add the second diagnosis, and then continue to see the patient for both issues in the same case.
What to do in WebPT

  1. Create a Re-Examination note for the patient’s existing case.
  2. Add the new diagnosis code in the Subjective tab. In the example below, the patient’s existing diagnosis is M54.40 – Lumbago, and the new diagnosis is M23.40 – Loose body in knee. 

  3. Continue treating the patient for both diagnoses in the same case.

B) Create separate cases for two diagnoses within the same specialty

If you’re seeing the patient on different days for each diagnosis—or, you believe the patient would be better off receiving treatment for one of the diagnoses from another therapist with the same specialty—then you’ll need to treat the cases separately instead of combining them.

What to do in WebPT

  1. Create a new case for the patient. If another therapist is going to treat this patient, then that therapist will create the case.
  2. Start an Initial Examination for the new case.
  3. Continue treating the patient as normal.

Scenario 5: Patient is receiving treatment from you on one case and from another therapist in your clinic who has a different specialty (e.g., you’re a PT and he or she is an OT) on a second case.

In this situation, each of you would complete treatment individually.

What to do in WebPT

  1. Ensure the patient has two separate cases—one for each specialty. 

Visits in Active Episode of Care

For Medicare patients, there’s a visit counter called “Visits in Active Episode of Care.” If your patient has multiple cases, this counter will include the total number of visits for all concurrent cases.This is important because to remain compliant with Medicare requirements, you must submit a Progress Note every ten visits, regardless of case. In other words, the total visit count includes visits from all concurrent cases (the entire episode of care). So, we created this visit counter to show you when a Progress Note is due.