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.
North Carolina Physical Therapy Documentation
What are a therapist’s documentation responsibilities?
A physical therapist shall document every evaluation and intervention or treatment including the following elements:
When does a therapist need to reassess the patient?
If a physical therapist assistant or physical therapy aide is involved in the patient care plan, a physical therapist shall reassess a patient every sixty (60) days or thirteen (13) visits, whichever occurs first.
What does a therapist need to document at the time of reassessment?
At the time of reassessment the physical therapist shall document:
A physical therapist shall, upon request by the patient of record, provide the original or copies of the patient’s treatment record to the patient, or to the patient’s designee. A fee may be charged for the cost of reproducing copies. The documents requested shall be provided within thirty (30) days of the request and shall not be contingent upon current, past, or future physical therapy treatment or payment of services.
21 NCAC 48C .0102
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.
Join today as either a monthly or a yearly member and enjoy full access to the site and a significant discount to our live and recorded webinars. Members also have access to compliance and billing support.