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
  Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  Practitioner, nurse, and ancillary progress notes
  Date the beneficiary started therapy
  PT/OT/SLP – Initial evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
  Initial evaluation/re-evaluation signed by ordering physician or practitioner
  Initial Certificate of Medical Necessity (CMN) and any recertification and/or revised CMNs
  Physician/Non-Physician Practitioner (NPP) certification of Plan of Care for Claim Period Including Justification when the Certification is Delayed More than 30 Days
  Proof of attempts if the required physician certification statement could not be obtained
  Documentation of pain level and activities of daily living (ADL) limitations, for example Roland Morris Disability Questionnaire.
  Functional Independent Measure (FIM) records
  Prior Level of Function (PLOF)
  Treatment plan
  Estimation of intellectual functioning, memory functioning, and orientation
  History and physical
  Progress reports written by the clinician-services related to progress reports are to be furnished on or before every 10th treatment day
  For all therapy services rendered submit attendance/treatment records for the claim period - must include total treatment time and identify each specific skilled modality provided
  Therapy logs that show services, dates and times for code billed
  Documentation of therapeutic activities
  Therapeutic activities program for beneficiary
  Documentation to support continued medical need
  Documentation supporting the diagnosis code(s) required for the item(s) billed
  Documentation to support the code(s) and modifier(s) billed
  List of all non-standard abbreviations or acronyms used, including definitions
  Other pertinent information
  Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Signature attestation and credentials of all personnel providing services
  If an electronic health record is utilized, include your facility’s process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)

 

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B 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 more information and resources.

 

Last Updated Thu, 26 Aug 2021 14:56:51 +0000

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.