When are treatment notes required?

Treatment notes are required for every treatment day, and every therapy service.

What is required to be included in the treatment note?

The date of treatment.

Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding.

Record of the total time spent in services represented by timed codes under timed code treatment minutes.

Record of the total treatment time in minutes, which is a sum of the timed and untimed services

Signature and credentials of each individual(s) that provided skilled interventions.

Who must sign the treatment note?

Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment (i.e., the signature of Kathleen Smith, PTA, with notation of phone consultation with Judy Jones, PT, supervisor, when permitted by state and local law).

Does the supervisor’s signature need to be on the note?

The signature and identification of the supervisor need not be on each treatment note, unless the supervisor actively participated in the treatment.

When the treatment is supervised without active participation by the supervisor, the supervisor is not required to cosign the treatment note written by a qualified professional. When the responsible supervisor is absent, the presence of a similarly qualified supervisor on the clinic roster for that day is sufficient documentation and it is not required that the substitute supervisor sign or be identified in the documentation.

References

Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services § 220.3

Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067