Medicare documentation is very important for physical therapy staff to be trained in. Without certain elements of that documentation, Medicare will refuse to pay for the services that patients have received. While that can be corrected later on, it is so much more work to do that. It is best to have it right the first time around. These tips will help with getting that Medicare documentation right. Then, patient care will be paid for by them in a timely manner.

• What has to be documented?

With Medicare, there are particular elements of patient care that have to be documented. This means that they are going to be checking for them. It is wise to make sure your physical therapy staff has a checklist that they can use to make sure they cover all of those essential elements.

Before any care can take place, there has to be documentation of the assessment. Then, there will be the documentation of the type of care plan that will be taking place. This includes details about what the patient will be taking part in, the estimated time frame for the physical therapy, such as twice a week for one month, and the results that are anticipated from the therapy.

After each session, there has to be updated notes for the patient placed into the patient file. These include that the patient showed up for the appointment, what took place at that appointment, and any observations that the physical therapist has made while working with the patient.

There will be an initial certification period that the physical therapist believes that the patient will be able to complete their needs in. However, there are times when the progress is slower than initially anticipated. When that occurs, this has to be documented as well. A recertification needs to be completed so that services can continue and will be approved by Medicare. They may require some additional forms to further provide verification that the ongoing physical therapy will really be a benefit to the patient.

• Authorization by licensed physician

Medicare won’t authorize any payments for physical therapy unless there is authorization from a licensed physician on file. This is to verify that the type of care needed can only be offered through physical therapy. If there is a chance that the patient can do exercises at home on their own at no cost, then Medicare won’t cover their physical therapy services.

The information for the licensed physician has to include their full name, location, and a contact phone number. There should also be a doctor’s order on file that explains the level of intensity that they would like to see the patient taking part in while they are part of the physical therapy program.

• Dictation

Medicare does consider dictation on the part of the physical therapist to be in compliance with their guidelines. However, they do state that the dictation needs to take place on the date that the patient was seen. It is necessary for written documentation to be created later on from that information. This enables the physical therapist to be able to legally edit and sign the documents later on, but it will still be considered documented on the date that the dictation was completed.

It is important to note that the requirements of Medicare documentation for physical therapy can change often. This means that you have to be able to continue to learn and to make changes to the setup in that work environment. Medicare policies will be passed along to administration. That gives them ample time to train the physical therapy staff. Such changes continue to ensure that the needs of the patients are always met successfully.

"Medicare audited our clinic and told me my WebPT documents were PERFECT!" Rick J, DPT, Clinic Owner, New York