Outpatient Therapy Services Targeted Probe and Educate Review Results

The Jurisdiction F, Part A Medical Review Department is conducting a Targeted Probe and Educate (TPE) review on outpatient therapy services. The findings of the claims reviewed from April 1, 2025 through June 30, 2025 are as follows:

Review Results

  • 405 claims were reviewed with 15% error rate

Top Trending Errors

  • Medical Necessity of Outpatient Therapy Services
  • Documentation Requirements for Therapy Services

Educational Resources

Education

Certification/Recertification/Plan of Care Requirements

The certification requires a qualified physician or nonphysician practitioner (NPP) signature and date on the plan of care or some other document to indicate approval of the plan of care. A plan of care outlines the treatment plan after an evaluation of a patient’s condition and is considered established when it is developed, e.g., written or dictated. The signature and professional credentials of the person who established the plan and the date must be supported in the documentation. The plan of care may only be developed by a practitioner or a licensed therapist specific to their specialty. For example, a physical therapist may develop a plan of care for physical therapy services but may not develop a plan of care for speech-language pathology. At a minimum, a plan of care must include the following:

  • Diagnosis
  • Long term treatment goals
  • Type, amount, frequency, and duration of therapy services
    • Frequency of therapy refers to "the number of times in a week the type of treatment is provided" which can be tapered as necessary. Long term treatment goals should be measurable and related to the patient’s impairments.

Certification requirements are met when the practitioner certifies the minimum required plan of care elements with a legible dated signature on the plan of care or some other document that indicates approval of the plan of care. If the order contains all the required elements of the plan of care and is legibly dated and signed by the practitioner, then no further certification is required. For claims with a date of service of January 1, 2025, and after, there is an exception for initial certifications. This exception allows for initial certification requirements to be met if there is a signed practitioner order for therapy services and the initial plan of care was sent to the practitioner within 30 days of the initial evaluation.

Timeliness is met when the initial certification is signed within 30 days of the initial treatment under that plan. Recertification of the minimum required plan of care elements must be legibly signed and dated by the practitioner during the duration of the prior plan of care or within 90 days, whichever is less. For example, if frequency and duration on the prior certified plan of care is documented as 2 times a week for 4 weeks, then that certification is valid for 4 weeks and the recertification must be completed by the practitioner within that 4 week time frame to meet the timeliness standard.

Delayed certification/recertification is acceptable without justification for an additional 30 day grace period after they are due. If the plan of care has not been legibly signed and dated within 60 days, the practitioner must also provide a rationale for the delay.

For additional information, refer to Internet-Only Manuals (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Sections 220(A) and 220.1.2 – 220.1.3.

Progress Report

The progress report(s) must provide justification of medical necessity for continued treatment and supports that required therapy services are complex and sophisticated such that they can only be safely and effectively provided by or under the supervision of a qualified therapist. The minimum progress report period shall be at least once every 10 treatment days which includes assessment of the patient’s response to therapy services, plans for continued treatment or treatment revisions, updates to short or long term goals and objective functional assessment. If each element required in a progress report is included in the treatment encounter notes, at least once during the progress reporting period, then a separate progress report is not required. Without the elements of the progress report documented in the medical record, medical necessity is difficult to establish. Routine assessment for progress reporting is included in the ongoing therapy services provided and is not separately billable.

Physical therapy assistants (PTAs) or occupational therapy assistants (OTAs) may write elements of the progress report dated between qualified therapist reports. Reports written by assistants are not complete progress reports. The qualified therapist must write a progress report during each progress report period regardless of when the assistant writes other reports.

For additional information, reference: Internet-Only Manuals (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Sections 220(A), 220.3(D), 220-230, and the billing and coding article, Medical Necessity of Therapy Services A52775 (JF).

Medical Necessity

To support medical necessity of therapy services, documentation must clearly support that the skills of a therapist were required.

Skilled care includes:

Individualized services rendered for treatment of a medical condition that require the skills and knowledge of a therapist

Services that meet acceptable standards of medical practice to effectively treat the patient’s condition

Services that are complex and sophisticated such that they require the judgement and skills of a qualified therapist for safe and effective completion

Rehabilitation services must be provided at a reasonable duration as evidenced by the patient continuing to significantly and objectively benefit from ongoing skilled therapy

As per the progress report requirements, documentation to support medical necessity for services is minimally required to be documented every 10 treatment days. Without the elements of the progress report documented, ongoing medical necessity is difficult to establish. Documentation must also support that the benefits from any prior therapy services for the same condition were sustainable following discharge for a reasonable amount of time.

The Internet-Only Manuals (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3(D) describes requirements for rehabilitative and skilled maintenance therapy as follows:

Rehabilitative Therapy: "the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time"

Maintenance Therapy: "treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel"

The KX modifier should not be applied for services that do not meet Medicare's medical necessity standard. Unskilled maintenance therapy is not covered by Medicare.

Documentation Requirements for Therapy Services and Billing

To support Medicare coverage, documentation must be sufficient to verify that therapy services were completed as billed and were completed at the level of care that was required. Insufficient or missing documentation may result in denied claims.

For additional information, refer to the Internet-Only Manuals (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Sections 220, 220.3(E), and 230.

Last Updated Jul 15 , 2025