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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.

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Documentation Requirements

Rendering providers must document all evaluations, re-evaluations, services provided, member progress, attendance records, and discharge plans. All documentation must be kept in the member's records along with a copy of the referral or prescribing provider's order. Documentation must support both the medical necessity of services and the need for the level of skill provided. Rendering providers must copy the member's primary care provider (PCP), prescribing provider and/or medical home on all relevant records.

All documentation must include the following:

    • The member's name and date of birth.
    • The date and type of service provided to the member.
    • The name or names and titles of the persons providing each service including assistants and the name and title of the therapist supervising or directing the services.

Health First Colorado requires the following types of documentation as a record of services provided within an episode of care: initial evaluation, re-evaluation, visit/encounter notes and a discharge summary.

Initial Evaluations

Written documentation of the initial evaluation must include the following:

  • Referral Information: Reason for referral and referral source.
  • History: Must include diagnoses pertinent to the reason for referral, including date of onset, cognitive, emotional, and/or physical loss necessitating referral, and the date of onset, if different from the onset of the relevant diagnoses, current functional limitation or disability as a result of the above loss, and the onset of the disability, pre-morbid functional status, including any pre-existing loss or disabilities, review of available test results, review of previous therapies/interventions for the presenting diagnoses, and the functional changes (or lack thereof) as a result of previous therapies or interventions.
  • Assessment: The assessment section must include a summary of the member's impairments, functional limitations and disabilities, based on a synthesis of all data/findings gathered from the evaluation procedures. Pertinent factors which influence the treatment diagnosis and prognosis must be highlighted, and the inter-relationship between the diagnoses and disabilities for which the referral was made must be discussed.

Plan of Care

A detailed Plan of Care must be included in the documentation of an initial evaluation. This care plan must include the following:

    • Specific treatment goals for the entire episode of care which are functionally-based and objectively measured
    • Proposed interventions/treatments to be provided during the episode of care
    • Proposed duration and frequency of services to be provided
    • Estimated duration of episode of care.

An episode of outpatient therapy is defined as the period of time from the first day the member is under the care of the clinician for the current condition(s) being treated by one therapy discipline until the last date of service for that plan of care for that discipline in that setting.

The therapist's plan of care must be reviewed, revised if necessary, and signed, as medically necessary by the member's physician, or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law at least once every 90 days.

The care plan may not cover more than a 90-day period, or the time frame documented in the approved IFSP.

A plan of care must be certified. Certification is the physician's, physician's assistant or nurse practitioner's approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. If the service is a Medicare-covered service and is provided to a member who is eligible for Medicare, the plan of care must be reviewed at the intervals required by Medicare.


A re-evaluation must occur whenever there is an unanticipated change in the member's status, a failure to respond to interventions as expected or there is a need for a new plan of care based on new problems and goals requiring significant modification of treatment plan. The documentation for a re-evaluation need not be as comprehensive as the initial evaluation, but must include at least the following:

    • Reason for re-evaluation
    • Member's health and functional status reflecting any changes
    • Findings from any repeated or new examination elements
    • Changes to plan of care

Treatment Notes

Written documentation of each encounter must be in the member's record of service. These visit notes document the implementation of the plan of care established by the therapist at the initial evaluation. Each visit note must include the following:

    • The member's name and date of birth.
    • The date of service.
    • The type of service provided to the member.
    • Total timed code treatment minutes and total treatment time in minutes.
      • Total treatment time includes the minutes for timed code treatment and untimed code treatment.
      • Total treatment time does not include time for services that are not billable (e.g., rest periods).
      • The time spent providing each service. The number of units billed/requested must match the documentation (billing and the total timed code treatment minutes must be consistent).
    • A description of each service provided during the encounter including procedure codes. The description should support each procedure code billed.
    • The name or names and titles of the persons providing each service including assistants and the name and title of the therapist supervising or directing the services.
    • Identification of the short or long-term goals being addressed during the encounter.

In addition to the above required information items, the visit note documentation must contain the Subjective, Objective, Assessment and Plan format elements. These may be documented in any order (i.e. SOAP, APSO, etc.)

    • A subjective element which includes the reason for the visit, the member/caregiver's report of current status relative to treatment goals, and any changes in member's status since the last visit,
    • An objective element which includes the practitioner's findings, including abnormal and pertinent normal findings from any procedures or tests performed,
    • An assessment component which includes the practitioner's assessment of the member's response to interventions provided, specific progress made toward treatment goals, and any factors affecting the intervention or progression of goals, and
    • A plan component that states the plan for the next visit(s).

Discharge Summary

At the conclusion of therapy services, a discharge summary must be included in the documentation of the final visit in an episode of care. This must include the following:

    • Highlights of a member's progress or lack of progress towards treatment goals.
    • Summary of the outcome of services provided during the episode of care.


Colorado Department of Health Care Policy & Financing

Physical and Occupational Therapy Billing Manual

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