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Checklist: Outpatient therapy and rehabilitation services (PT, OT, ST)

This checklist is intended to provide healthcare providers with a reference for use when responding to additional documentation requests for outpatient therapy and rehabilitation services. It is not intended to replace the published guidelines. Healthcare providers retain responsibility to submit complete and accurate documentation.

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Documentation description

  Documentation is for the correct beneficiary and date of service.

  Documentation is complete, legible, signed, and dated by the physician or clinician, which follows CMS Signature Guidelines for Medical Review Purposes.

 

Documentation submitted includes the initial evaluation and plan of care with documented goals of therapeutic intervention that include the following:

  • Diagnoses.
  • Long term treatment goals: Should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care.
  • Type: May be physical therapy, occupational therapy, or speech language pathology, or when appropriate, the type may be a description of a specific treatment or intervention. When a physician or NPP (non-physician practitioner) establishes a plan, the plan must specify the type of therapy planned.
  • Amount: Refers to the number of times in a day the type of treatment will be provided.
  • Duration: Number of weeks or the number of treatment sessions for the plan of care.
  • Frequency of therapy services: Refers to the number of times in a week the type of treatment is provided.
  • Modifications: If any modifications are made to the plan of care, it should include how it has been modified and why the previous goals were not met or could not be met.

 

Documentation includes physician certification or recertification of the plan of care and therapy goals and date established. Certification requires a signature and date indicating approval of the plan of care.

  • A physician/NPP may certify a plan of care for an interval length that is less than 90 days.
  • The physician/NPP Certification of the initial care plan needs to be signed and dated at the time it is obtained or within 30 days of the initial therapy treatment:
  • The physician/NPP Certification of the modified care plan needs to be signed and dated within 30 days of the initial modified plan of care.
  • If verbal certification is obtained, signature need to be obtained within 14 days to be timely.
  • Beneficiary's need to be recertified at minimum every 90 days.

 

Documentation should include treatment notes and log that includes the following information:

  • Date of treatment.
  • Identification of each specific intervention/modality provided and billed (both timed and untimed codes).
  • Total timed code treatment minutes and total treatment time in minutes.
  • Signature and professional identification of the qualified professional who furnished the services; or, for incident to services, supervised the services, including a list of each person who contributed to the treatment.
 

Documentation incorporates progress reports justifying the medical necessity of treatment.

  • Minimum report period shall be at least every ten (10) treatment days or a date chosen by the clinician, whichever is shorter.
  • Information required shall be written by a clinician that is, either the physician/NPP who provides or supervises the services or by the therapist who provides the services and supervises an assistant.

  If applicable and required, submitted documentation should include a beneficiary waiver of liability.

 

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.