How familiar are you with the Medicare guidelines for physical therapy documentation? What about for occupational therapy documentation? If you’re a PT or OT—and you’re anything less than 100% confident in your knowledge of the Medicare documentation rules that apply to your specialty—then you’ve come to the right place. Failing to adhere to these standards could mean problems—both in the form of denied reimbursements and potential audits. So, read on and make sure you’re totally up to snuff on all Medicare Part B physical and occupational therapy documentation requirements. (As a side note, if you’re looking for Medicare Part A therapy documentation requirements, click here; for CMS documentation guidelines for speech-language pathology, click here.)

Medicare Rules for Documentation

Medicare reimburses for Part B physical and occupational therapy services when the claim form and supporting documentation accurately report medically necessary covered services. Thus, developing legible and relevant documentation is only one piece of the reimbursement puzzle. Your documentation must also:

  • Justify the services you bill;
  • Comply with all applicable Medicare regulations (including those associated with FLR );
  • Support any listed CPT codes (including these ones that went into effect in January 2017); and
  • Conform to state and local laws as well as the professional guidelines of the American Physical Therapy Association (APTA) or the American Occupational Therapy Association (AOTA)—even if Medicare’s requirements are less stringent.

In other words, your documentation must be defensible (and this stands whether you’re billing Medicare or any other payer). As we explained in this resource, “Defensible documentation supports clinical decision-making—and ensures providers adhere to agreed-upon standards of practice. It’s essentially a historical record of your patients’ conditions and progress as well as your treatment interventions. To that end, defensible documentation serves three main purposes:

  1. Communication 
  2. Payment Justification 
  3. Legal Protection/Risk Mitigation”

That said, it’s entirely unnecessary to “document every single minute detail of each patient interaction.” Instead, make sure that you’re accurately “telling the patient’s story—and being clear about his or her need for physical therapy services.” This last part is especially important, because Medicare only covers services that are medically necessary, and medical necessity requires that patients wouldn’t benefit from services performed by a non-licensed provider. That means your documentation must explicitly demonstrate why your patients need your services, as opposed to, say, a personal trainer’s.

To accomplish that, you’ll want to ensure you’re:

  • “Accounting for all complicating factors;
  • “Detailing specific functional deficits;
  • “Explaining how those deficits impact the patient’s independence and activities of daily living;
  • “Communicating whether the patient is improving or regressing; and
  • “Providing relevant and unique details that arise during each patient visit (in other words, avoid being repetitive).”

The Elements of Patient Care

For Medicare Part B beneficiaries, therapists must document the following elements of patient care:

The Evaluation

Before starting treatment, the licensed therapist must complete an initial evaluation of the patient, which includes:

  • Medical diagnosis
  • Treating impairment or dysfunction
  • Subjective observation
  • Objective observation (e.g., identified impairments and their severity or complexity)
  • Assessment (including rehab potential)
  • Plan (information pertinent to the plan of care)

And, of course, all of this should be accounted for you in your documentation. You might recognize the last four items as the foundation of your SOAP notes.

The Plan of Care (POC)
  • Based on the assessment, the therapist then must create a POC—complete with treatment details, the estimated treatment time frame, and the anticipated results of treatment. At minimum, Medicare requires the POC to include:
  • Medical diagnosis
  • Long-term functional goals
  • Type of services or interventions performed
  • Quantity of services or interventions (i.e., the number of times per day the therapist provides treatment; if the therapist does not specify a number, Medicare will assume one treatment session per day)
  • Frequency of treatment (i.e., the number of times per week; do not use ranges) and duration of treatment (i.e., length of treatment; again, do not use ranges)

Additionally, if a patient is receiving therapy services in multiple disciplines (e.g., PT, OT, and SLP), then there must be a POC for each specialty, and each therapist must independently establish:

  • what impairment or dysfunction he or she is treating, and
  • the goals for therapy treatment.
POC Certification

Medicare requires that a licensed physician or nonphysician practitioner (NPP) date and sign the POC within 30 days. To make things easier, though, the certifying physician doesn’t have to be the patient’s regular physician—or even see the patient at all (although some physicians do require a visit). According to CMS, the certifying provider can be “a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only).” However, “chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.”

Another tip: To avoid an automatic claim denial from Medicare, be sure to list the certifying provider’s name and NPI number in the ordering/referring physician field on the claim form.

POC Recertification

As we mentioned above, the plan of care specifies the frequency and duration of treatment. Essentially, providers denote the amount of therapy time they expect a patient will need in order to achieve his or her functional goals. However, things don’t always go as planned, and sometimes patient progress can be slower than anticipated. When this occurs, the licensed therapist must document what has happened and complete a recertification, which must be signed by a physician or NPP. In some cases, Medicare may require additional documentation to verify that the patient needs additional therapy beyond what was originally proposed. And even when things do go according to plan, Medicare requires recertification after 90 days of treatment.

If you’re a WebPT Member, you can use WebPT’s Plan of Care Report to identify which plans of care are still pending certification as well as which ones require certification—before those 90 days are up.

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The Daily Note (a.k.a. The Treatment Note)

To complete a daily note, a provider must update the patient file for each therapy visit, including at least the following information:

  • The date of service
  • What took place at that session (i.e., all services provided)
  • How much time the provider spent performing each service
  • Whether anything changed, including any additions or deletions of treatments or modalities
  • Any observations the provider made while working with the patient

Regarding the specificity of daily notes, the Coverage Manual, IOM Pub. 100-02, Chapter 15, §220.3. E. Treatment Note reads: “The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of the billing codes on the claim form. Documentation is required for every treatment day and every therapy service. The format shall not be dictated by the contractor and may vary depending on the practice of the responsible clinician and/or clinical setting…The Treatment Note is not required to document medical necessity or appropriateness of the ongoing therapy services. Descriptions of skilled interventions should be included in the plan or progress note and are allowed, but not required daily.”

All that said, WebPT’s in-house billing experts Dianne Jewell, PT, DPT, PhD, FAPTA, and John Wallace, PT, MS, believe that “including detail beyond the gym-record style of notation is worth the extra time, as it can help auditors understand why you submitted the codes you did on the claim.” 

The Role of Therapist Assistants

As we explained in this article, per Medicare, a therapist assistant may provide treatment—and complete daily note documentation—for patients in an outpatient private practice setting under the direct supervision of a licensed therapist. However, in order to receive payment for services provided by an assistant, you must not only meet all of Medicare’s conditions, but also document that you’ve done so. Here are a few tips from compliance expert Tom Ambury to help you do just that:

  1. Document that you’ve reviewed the POC with the assistant who’s providing the services under your direction.
  2. Make notes of regular patient progress review meetings with the assistant.
  3. Explain if/when the treatment advances to the next more complex task.
  4. Cosign the daily note and request that your assistant document that he or she “provided services under the direct supervision of (name of the supervising therapist).”

Please note that daily notes are the only documentation that a therapist assistant may complete, as the licensed therapist must handle anything that requires clinical assessment or analysis.

The Progress Report

At minimum, a licensed therapist must complete a progress note—a.k.a. progress report—for every patient by his or her tenth visit. In it, the therapist must:

  • Include an evaluation of the patient’s progress toward current goals.
  • Make a professional judgment about continued care.
  • Modify goals and/or treatment, if necessary.
  • Terminate services, if necessary (see the discharge note section below).

According to Jewell and Wallace, “The Medicare progress report is intended to address the patient’s progress toward his or her goals as noted in the established plan of care. Simply documenting treatment provided on the tenth visit does not meet this requirement—even if you conduct follow-up standardized testing and record results.”

It’s also important to note that while you may bill for re-evaluations, you cannot bill for progress notes. In a progress note, you’re simply justifying the continued medical necessity of your care. Furthermore, it’s not appropriate to bill for a re-evaluation when you’re only completing a routine progress note. As we discussed here, the circumstances under which you should perform and bill for a re-eval are actually pretty limited. Doing so regularly could throw up a big red flag.

The Discharge Summary Note

To complete a discharge note, the licensed therapist must detail the conclusion of a patient’s care and his or her subsequent discharge. As we explained in this post, at discharge, defensible documentation should “include an objective summary comparing the patient’s status when treatment began to his or her status at the end of treatment.” 


Looking for even more documentation best practices? Download your free copy of our Defensible Documentation toolkit today. In addition to really useful recommendations for ensuring your documentation withstands scrutiny, you’ll also receive in-depth documentation examples and strategies for performing an internal audit. After all, better you than Medicare, right?