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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

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 for the Individual Needs of the Patient
  • Needs of the Patient
  • Dictated Documentation
  • Dates for Documentation

Evaluations and Re-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
  • Re-Evaluations

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

Discharge Note

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

Functional Reporting (No Longer Required as of January 1, 2019)

  • Services Affected
  • Providers and Practitioners Affected
  • Function-Related G-codes
  • Selecting the G-codes to use in Functional Reporting
  • Choosing the Correct Severity/Complexity Modifiers
  • Required Reporting of Functional G-codes and Severity Modifiers

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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