Upcoming Webinars

Site Updates

Disclaimer

The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Menu
Log in
Forgot password


Search
Log in
Forgot password

Medicare Treatment Note FAQs

Posted November 11, 2022

See Medicare Documentation for more information.

What is a treatment note?

A record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service.

What is required in each note?

The treatment note must include the following required information:

    • Date of treatment;
    • Identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;
    • Record of the total time spent in services represented by timed codes under timed code treatment minutes;
    • Record of the total treatment time in minutes, which is a sum of the timed and untimed services;
    • Signature and credentials of each individual(s) that provided skilled interventions.

Is there additional information that can be added to the note?

The treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:

    • Patient comments regarding pain, function, completion of self-management/home exercise program (HEP), etc;
    • Significant improvement or adverse reaction to treatment;
    • Significant, unusual or unexpected changes in clinical status;
    • Parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;
    • Description of the skilled components of the specific exercises, training, or activities;
    • Instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;
    • Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);
    • Communication with patient, family, caregiver;
    • Equipment provided
    • Any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.

When does the note need to be completed?

Medicare contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the progress report or treatment note refers.

Who must sign the treatment note?

Signature and professional identification of the qualified professional (therapist or assistant) who furnished or supervised the services and a list of each person who contributed to that treatment.

When the treatment is supervised without active participation by the supervisor, the supervisor is not required to cosign the treatment note written by a qualified professional.

State law may require that the supervising therapist co-sign the note with the assistant.

Reference

Centers for Medicare and Medicaid

Medicare Benefit Policy Manual

Chapter 15 – Covered Medical and Other Health Services

About Us

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

Learn More 

Join Us

Join today as a yearly member and enjoy full access to the site and a significant discount to our live and recorded webinars.  Members also have access to compliance and billing support.

Join Today 

Find Us


Powered by Wild Apricot Membership Software