See our Medicare Progress Report section for more guidance.

Who must complete the progress report?

Information required in progress reports shall be written by a clinician that is, either the physician/NPP who provides or supervises the services, or by the therapist who provides the services and supervises an assistant.

Who must sign the report?

The clinician who completed the report must sign and date report.

It is not required that the referring or supervising physician/NPP sign the progress reports written by a PT, OT or SLP.

When does the progress report need to be completed?

The minimum progress report period shall be at least once every ten (10) treatment days. The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, reevaluation or treatment.

The next treatment day begins the next reporting period. The progress report period requirements are complete when both the elements of the progress report and the clinician’s active participation in treatment have been documented.

What happens if the report is delayed?

If the clinician has not written a progress report before the end of the progress reporting period, it shall be written within 7 calendar days after the end of the reporting period. If the clinician did not participate actively in treatment during the progress report period, documentation of the delayed active participation shall be entered in the treatment note as soon as possible. The treatment note shall explain the reason for the clinician’s missed active participation. Also, the treatment note shall document the clinician’s guidance to the assistant or qualified personnel to justify that the skills of a therapist were required during the reporting period. It is not necessary to include in this treatment note any information already recorded in prior treatment notes or progress reports.

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