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.
Massachusetts Physical Therapy Documentation
What are a therapist’s documentation responsibilities?
A physical therapist shall document, date, and authenticate the patient’s clinical examination, evaluation, diagnosis, prognosis, progress, and any clinical assessment of the patient’s condition which results in an alteration in the patient’s plan of care.
When does a therapist need to reassess the patient?
This documentation shall be contained in the patient’s ongoing treatment notes or in a formal review of the plan of care (or reevaluation). If by formal review of the plan of care (or reevaluation), it must be completed in the particular work setting by a physical therapist of record within the following timeframes:
Each visit or patient encounter must be documented, including at a minimum:
259 CMR 5.03
Therapy Comply is a healthcare compliance firm that seeks to bring high quality web-based compliance guidance and one-on-one consulting services to small and medium size physical, occupational, and speech therapy practices.
Join today as either a monthly or 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.