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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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Medicare Treatment Notes

Medical record documentation is required for every treatment day, and every therapy service to justify the use of codes and units on the claims.

Treatment Notes FAQs

    • 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?

Content Requirements for Specific Services

    • Phonopheresis
    • Therapeutic Exercise
    • Group Therapy
    • Physical Performance Test or Measurement
    • Assistive Technology Assessment

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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