Posted on November 23, 2022

See our Medicare Progress Report section for more information.

Who must complete the progress report?

Information required in progress reports shall be written by a clinician that is, either the physician/NPP who provides or supervises the services, or by the therapist who provides the services and supervises an assistant.

Who must sign the report?

The clinician who completed the report must sign and date report.

It is not required that the referring or supervising physician/NPP sign the progress reports written by a PT, OT or SLP.

When does the progress report need to be completed?

The minimum progress report period shall be at least once every ten (10) treatment days. The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, reevaluation or treatment.

The next treatment day begins the next reporting period. The progress report period requirements are complete when both the elements of the progress report and the clinician’s active participation in treatment have been documented.

What happens if the patient is absent during the report period?

Holidays, sick days or other patient absences may fall within the progress report period. Days on which a patient does not encounter qualified professional or qualified personnel for treatment, evaluation or re-evaluation do not count as treatment days.

Absences do not affect the requirement for a progress report at least once during each progress report period. If the patient is absent unexpectedly at the end of the reporting period, when the clinician has not yet provided the required active participation during that reporting period, a progress report is still required, but without the clinician’s active participation in treatment, the requirements of the progress report period are incomplete.

What happens if the report is delayed?

If the clinician has not written a progress report before the end of the progress reporting period, it shall be written within 7 calendar days after the end of the reporting period. If the clinician did not participate actively in treatment during the progress report period, documentation of the delayed active participation shall be entered in the treatment note as soon as possible.

The treatment note shall explain the reason for the clinician’s missed active participation. Also, the treatment note shall document the clinician’s guidance to the assistant or qualified personnel to justify that the skills of a therapist were required during the reporting period. It is not necessary to include in this treatment note any information already recorded in prior treatment notes or progress reports.

What does active participation mean?

Active participation of the clinician in treatment means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.

Verification of the clinician’s required participation in treatment during the progress report period shall be documented by the clinician’s signature on the treatment note and/or on the progress report. When unexpected discontinuation of treatment occurs, contractors shall not require a clinician’s participation in treatment for the incomplete reporting period.

Can the progress report be part of that day’s treatment note?

Elements of progress reports may be written in the treatment notes if the provider/supplier or clinician prefers. If each element required in a progress report is included in the treatment notes at least once during the progress report period, then a separate progress report is not required.

What must be included in the progress report?

Progress reports shall include:

• Date of the beginning and end of the reporting period that this report refers to;
• Date that the report was written (not required to be within the reporting period);
• Signature, and professional identification, or for dictated documentation, the identification of the qualified professional who wrote the report and the date on which it was dictated;
• Assessment of improvement, extent of progress (or lack thereof) toward each goal;
• Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report; and
• Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.
• Objective reports of the patient’s subjective statements, if they are relevant. For example, “Patient reports pain after 20 repetitions”. Or, “The patient was not feeling well on 11/05/06 and refused to complete the treatment session.”; and
• Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occur. Note that assistants may not make clinical judgments about why progress was or was not made, but may report the progress objectively. For example: “increasing strength” is not an objective measurement, but “patient ambulates 15 feet with maximum assistance” is objective.

How can the progress report be used to justify medical necessity?

Care must be taken to assure that documentation justifies the necessity of the services provided during the reporting period, particularly when reports are written at the minimum frequency. Justification for treatment must include, for example, objective evidence or a clinically supportable statement of expectation that:

• In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.
• In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.

Objective evidence consists of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome. Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment. Such tools are not required, but their use will enhance the justification for needed therapy.

Can an assistant participate in the report?

PTAs or OTAs may write elements of the progress report dated between clinician reports. Reports written by assistants are not complete progress reports. The clinician must write a progress report during each progress report period regardless of whether the assistant writes other reports. However, reports written by assistants are part of the record and need not be copied into the clinicians report.

References

Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services § 220.3

Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067