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
  • On or before every 10th treatment day
  • Changes to goals
  • Plan for continuing treatment
  Physician/Non-Physician Practitioner (NPP) certification and recertifications
  • Reason for delay, if appliable
  Signed and dated overall plan of care
  • Short and long term goals
  • Diagnosis
  • Type, amount, duration, and frequency of therapy
  • Changes to plan of care
  Therapy logs and treatment encounter notes
  • Total treatment time
  • Specify modality
  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. 

View the Outpatient Therapy webpage for additional information and resources.

 

Last Updated Thu, 20 Aug 2020 14:39:27 +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.