Outpatient Therapy Documentation Requirements - JF Part B
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 |
|---|---|
| PT/OT/SLP - Initial evaluation, plan of care, progress reports, treatment encounter notes, discharge summary, therapy PT/OT/SLP - Progress reports, encounter notes and therapy minute logs and discharge summary | |
| Progress reports written by the clinician-services related to progress reports are to be furnished on or before every 10th treatment day | |
| Initial Evaluation/Re-evaluation Signed by Ordering Physician or Practitioner | |
| All physician signed certifications & recertifications since the initial evaluation | |
| Therapy logs that show services, dates and times for code billed | |
| Treatment plan | |
| 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 | |
| Beneficiary name and date of service on all documentation | |
| Documentation as required in LCD or NCD | |
| Any additional documentation to support the reasonable necessity of the service(s) performed | |
| Advance Beneficiary Notice | |
| 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 |
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.
- Noridian Medical Review: Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request
View the Outpatient Therapy webpage for more information and resources.
Last Updated Wed, 22 Jul 2020 16:53:49 +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.