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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 for Therapy Services

Therapy Comply's Medicare documentation guides for physical, occupational, and speech therapy. Members have full access to the material and can contact us with questions regarding any billing or compliance issue, please consider joining today if you need assistance.

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

General Documentation 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 
    • Dates for Documentation
    • Tips for Good Documentation
    • Medicare Retention Requirements

Evaluations

    • 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 Medicare require for a certification?
    • Which providers can certify a POC?
    • When does the POC need to be certified?
    • What if I am having trouble getting the physician’s certification?
    • What if the physician fails to date the certification?
    • Is there a specific way the certification has to be formatted?
    • What happens if the certification is delayed?
    • When is recertification required?
    • What happens if payment is denied due to certification?

Progress Reports 

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

Treatment Notes

    • When are treatment notes required?
    • What if the note is not completed on the same day as treatment?
    • What is required to be included in the treatment note?
    • What information is optional but recommended?
    • What information is not required in the treatment note?
    • What are some tips for writing notes?
    • What need to be included if I use a grid form?
    • Who must sign the treatment note?
    • Does the supervisor’s signature need to be on the note
    • Examples for Specific Services

Reevaluations

    • Does Medicare require routine re-evaluations or reassessments?
    • When is a re-evaluation covered by Medicare?
    • Who can perform a re-evaluation?
    • What documentation must be included in a re-evaluation?
    • Is a re-evaluation the same as an assessment?
    • What are some examples of situations where a re-evaluation is appropriate?
    • Billing for a Reevaluation

Discharge Summary

    • Is a discharge summary required for every patient?
    • What if the patient just stops coming to therapy?
    • What is required on the discharge summary?
    • What if a progress report was done close to the anticipated discharge date?

    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?


    About Us

    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.

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