Physical therapists must be mindful of the following documentation requirements for Medicare Part B. If you have questions, contact firstname.lastname@example.org.
Evaluation and Plan of Care
Include the initial evaluation and any re-evaluations relevant to the episode being reviewed.
- A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. The diagnosis should be specific and as relevant to the problem to be treated as possible. Include all conditions and complexities that may impact the treatment. A description might include, for example, the premorbid function, date of onset, and current function (FLR codes and documentation);
- Clinician's clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools;
- A determination that treatment is not needed, or, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.
Plan of care:
- Long term treatment goals; and
- Type, amount, duration and frequency of therapy services.
Certification (physician/NPP approval of the plan) is required for payment and must be submitted when records are requested after the certification or recertification is due.
Progress reports, including discharge notes, if applicable, must be completed at a minimum of every 10 visits (dates of service);
- Assessment of improvement, extent of progress (or lack thereof) toward each goal;
- Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician's progress report; and
- Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.
- Functional documentation is required as part of the progress report at the end of each progress reporting period (FLR codes and documentation).
Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes);
- Date of treatment; and
- Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding;
- Total timed code treatment minutes and total treatment time in minutes. Total treatment time includes the minutes for timed code treatment and untimed code treatment. Total treatment time does not include time for services that are not billable (e.g., rest periods);
- Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment.