Outpatient Therapy Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check Brief Description
  Legible handwritten physician and/or clinician signatures
  Valid electronic physician and/or clinician signatures
  Physician or Non-Physician Practitioner (NPP) order for date of service when evaluation is only service
  Treatment encounter note for each treatment day to support services billed
  • Date of treatment
  • Identification of each specific intervention/modality provided and billed for both timed and untimed codes
  • Total timed code treatment minutes and total treatment time in minutes
  • Signature and professional identification of qualified professional who furnished or supervised services including a list of each person who contributed to that treatment
  Initial evaluation and any re-evaluations relevant to episode being reviewed
  Plans of care
  • Diagnoses
  • Long term treatment goals
  • Type, amount, duration and frequency of therapy services
  • Signature and professional identify of person who established plan
  • Date plan was established
  All progress reports since initial evaluation
  • Assessment of improvement, extent of progress (or lack thereof) toward each goal
  • Plans for continuing treatment, reference to additional evaluation results and/or treatment plan revisions
  • Changes to long or short term goals, discharge or an updated plan of care sent to physician
  • Functional assessment documentation
  All physician signed certifications and recertifications since initial evaluation
  • Delayed certification with reason for delay
  Records of patient's condition to justify
  • The patient is under the care of a physician/NPP
  • Services require the skills of a therapist
  • Services are appropriate type, frequency, intensity and duration for individual needs of patient
  • Functional information including patient's current, projected goal and discharge status
  Discharge summary, if applicable
  Itemization of services
  Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable
  Advance Beneficiary Notice of Noncoverage (ABN), if applicable

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors. 

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions. 

View the Outpatient Therapy webpage for additional information and resources.

Last Updated Feb 08, 2019

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.