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Documentation for Therapy Services

Therapy Comply's Medicare documentation guides for physical, occupational, and speech therapy.  

Sample Audit Form - Can be used to audit outpatient therapy documentation. 

General Documentation Requirements

    • Document Requirements
    • The Patient is under the Care of a Physician/NPP
    • Services Require the Skills of a Therapist
    • Services are of Appropriate Type, Frequency, Intensity and Duration 
    • Needs of the Patient
    • Dictated Documentation
    • Dates for Documentation


    • When it is Appropriate for an Initial Evaluation
    • Contents of an Evaluation
    • When the Evaluation is the Only Service Provided
    • When the Evaluation Serves as the Plan of Care
    • Additional Assessments
    • Evaluations by Multiple Disciplines

Plan of Care

    • Establishing the Plan of Care
    • Elements of the Plan of Care
    • Modifying the Plan of Care

Certification and Re-certification of the Treatment Plan

    • What does it mean to have the plan of care certified?
    • Do I need an order/prescription/referral from a physician/NPP?
    • When does the POC need to be certified?
    • Is the initial treatment date when I began treating the patient or when I performed the evaluation?
    • How long do certifications last?
    • What happens if I can’t get the plan certified within ninety (90) days?
    • Do I need to submit additional evidence to justify the delay?
    • Who must certify the POC?
    • Which practitioners are not allowed to certify a plan of care?
    • Can I have the physician/NPP sign a document other than the POC?
    • Are verbal certifications acceptable?
    • When does the POC need to be recertified?
    • What happens if the recertification is delayed?
    • What happens if my claim is denied due to certification issues?

Progress Reports 

    • Timing of the Progress Report
    • Content of the Progress Report
    • Clinician’s Participation in the Report
    • Assistant’s Participation in the Report

Treatment Notes

    • Required Elements
    • Optional Elements
    • Additional Tips for Notes
    • Making Changes to the Note
    • Signature on the Note
    • Identification of the Supervisor


    • Who may Perform a Reevaluation?
    • Role of the Assistant
    • When can a Reevaluation be Performed?
    • Reimbursement
    • Content of the Reevaluation
    • Billing for a Reevaluation
    • Documentation

Discharge Summary

    • What is Required in the Discharge Note?
    • Unanticipated Discharge
    • Optional Information

    Medicare Signature Requirements

      • Which outpatient therapy documentation requires and signature and who must sign?
      • What is required for a valid signature?
      • What if I use a scribe when documenting medical record entries?
      • How are orders treated differently than other medical documentation?
      • What should I do if I did not sign an order or medical record?
      • What if I signed the order or progress note but my signature is not legible?
      • What is a signature log?
      • What if I do not have a signature log in place?
      • Am I able to attest to my signature?
      • Do my signatures need to be dated?

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