Medical review findings continue to show that many therapy claim denials result from missing documentation. Providers can help prevent denials by ensuring the medical record includes all required therapy documentation.

Top Documentation Errors

Missing Certification/Recertification

• Signed and dated certification or recertification of the therapy plan of care is not included in the medical record.

Missing Plan of Care

• Therapy plan of care is missing or incomplete.
• Required elements such as long-term goals, frequency, duration, or treatment plan are not documented.

Missing Progress Reports

• Required progress reports are not completed at least every 10 treatment days.
• Progress reports do not include objective findings, outcome measures, or the patient's progress toward goals.

Provider Reminder Before submitting a claim or responding to a documentation request, verify that the record includes:

• Signed and dated certification/recertification
• Complete therapy plan of care
• Treatment notes supporting the billed services and units
• Required progress reports with outcome measurements

Thorough documentation helps support medical necessity and reduces the risk of claim denials during medical review.