Outpatient Therapy Documentation Requirements - JF Part A
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 |
|---|---|
| Physician/Non Physician Practitioner (NPP) order or evidence of intent to order, if applicable | |
| Initial evaluation and re-evaluation | |
Progress reports written by the clinician
| |
Physician/Non-Physician Practitioner (NPP) certification and recertifications
| |
Signed and dated overall plan of care
| |
Therapy logs and treatment encounter notes
| |
| Support LCD and NCD requirements, if applicable | |
| Itemization of services | |
| Advance Beneficiary Notice | |
| Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services) | |
| Facility process of how electronic signature is created if using electronic health record |
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.
- Noridian Medical Review: Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request
View the Outpatient Therapy webpage for additional information and resources.
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.
