CMS Pub. 100-02, ch. 15, § 220.3

A. General

To be payable, the medical record and the information on the claim form must

consistently and accurately report covered therapy services, as documented in the medical

record. Documentation must be legible, relevant and sufficient to justify the services

billed. In general, services must be covered therapy services provided according to

Medicare requirements. Medicare requires that the services billed be supported by

documentation that justifies payment. Documentation must comply with all requirements

applicable to Medicare claims.

The documentation guidelines in sections 220 and 230 of this chapter identify the

minimal expectations of documentation by providers or suppliers or beneficiaries

submitting claims for payment of therapy services to the Medicare program. State or

local laws and policies, or the policies or professional guidelines of the relevant

profession, the practice, or the facility may be more stringent. It is encouraged but not

required that narratives that specifically justify the medical necessity of services be

included in order to support approval when those services are reviewed. (See also section

220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services)

Contractors shall consider the entire record when reviewing claims for medical necessity

so that the absence of an individual item of documentation does not negate the medical

necessity of a service when the documentation as a whole indicates the service is

necessary. Services are medically necessary if the documentation indicates they meet the

requirements for medical necessity including that they are skilled, rehabilitative services,

provided by clinicians (or qualified professionals when appropriate) with the approval of

a physician/NPP, safe, and effective (i.e., progress indicates that the care is effective in

rehabilitation of function).

B. Documentation Required

List of required documentation. These types of documentation of therapy services are

expected to be submitted in response to any requests for documentation, unless the

contractor requests otherwise. The timelines are minimum requirements for Medicare

payment. Document as often as the clinician’s judgment dictates but no less than the

frequency required in Medicare policy:

• Evaluation and Plan of Care (may be one or two documents). Include the initial

evaluation and any re-evaluations relevant to the episode being reviewed;

• Certification (physician/NPP approval of the plan) and recertifications when

records are requested after the certification/recertification is due. See definitions in

section 220 and certification policy in section 220.1.3 of this chapter. Certification (and

recertification of the plan when applicable) are 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) when records are

requested after the reports are due. (See definitions in section 220 and descriptions in

220.3 D);

• Treatment notes for each treatment day (may also serve as progress reports when

required information is included in the notes);

• A separate justification statement may be included either as a separate document

or within the other documents if the provider/supplier wishes to assure the contractor

understands their reasoning for services that are more extensive than is typical for the

condition treated. A separate statement is not required if the record justifies treatment

without further explanation.

Limits on Requirements. Contractors shall not require more specific documentation

unless other Medicare manual policies require it. Contractors may request further

information to be included in these documents concerning specific cases under review

when that information is relevant, but not submitted with records.

Dictated Documentation. For Medicare purposes, dictated therapy documentation is

considered completed on the day it was dictated. The qualified professional may edit and

electronically sign the documentation at a later date.

Dates for Documentation. The date the documentation was made is important only to

establish the date of the initial plan of care because therapy cannot begin until the plan is

established unless treatment is performed or supervised by the same clinician who

establishes the plan. However, contractors may require that treatment notes and progress

reports be entered into the record within 1 week of the last date to which the progress

report or treatment note refers. For example, if treatment began on the first of the month

at a frequency of twice a week, a progress report would be required at the end of the

month. Contractors may require that the progress report that describes that month of

treatment be dated not more than 1 week after the end of the month described in the

report.

Document Information to Meet Requirements. In preparing records, clinicians must be

familiar with the requirements for covered and payable outpatient therapy services. For

example, the records should justify:

• The patient is under the care of a physician/NPP;

Physician/NPP care shall be documented by physician/NPP certification

(approval) of the plan of care; and

Although not required, other evidence of physician/NPP involvement in the

patient’s care may include, for example: order/referral, conference, team

meeting notes, and correspondence.

• Services require the skills of a therapist.

Services must not only be provided by the qualified professional or qualified

personnel, but they must require, for example, the expertise, knowledge,

clinical judgment, decision making and abilities of a therapist that assistants,

qualified personnel, caretakers or the patient cannot provide independently. A

clinician may not merely supervise, but must apply the skills of a therapist by

actively participating in the treatment of the patient during each progress

report period. In addition, a therapist’s skills may be documented, for

example, by the clinician’s descriptions of their skilled treatment, the changes

made to the treatment due to a clinician’s assessment of the patient’s needs on

a particular treatment day or changes due to progress the clinician judged

sufficient to modify the treatment toward the next more complex or difficult

task.

• Services are of appropriate type, frequency, intensity and duration for the

individual needs of the patient.

Documentation should establish the variables that influence the patient’s

condition, especially those factors that influence the clinician’s decision to

provide more services than are typical for the individual’s condition.

Clinicians and contractors shall determine typical services using published

professional literature and professional guidelines. The fact that services are

typically billed is not necessarily evidence that the services are typically

appropriate. Services that exceed those typically billed should be carefully

documented to justify their necessity, but are payable if the individual patient

benefits from medically necessary services. Also, some services or episodes

of treatment should be less than those typically billed, when the individual

patient reaches goals sooner than is typical.

Documentation should establish through objective measurements that the

patient is making progress toward goals. Note that regression and plateaus

can happen during treatment. It is recommended that the reasons for lack of

progress be noted and the justification for continued treatment be documented

if treatment continues after regression or plateaus.

Needs of the Patient. When a service is reasonable and necessary, the patient

also needs the services. Contractors determine the patient’s needs through

knowledge of the individual patient’s condition, and any complexities that

impact that condition, as described in documentation (usually in the

evaluation, re-evaluation, and progress report). Factors that contribute to need

vary, but in general they relate to such factors as the patient’s diagnoses,

complicating factors, age, severity, time since onset/acuity, self-efficacy/motivation, cognitive ability, prognosis, and/or medical,

psychological and social stability. Changes in objective and sometimes to

subjective measures of improvement also help establish the need for

rehabilitative services. The use of scientific evidence, obtained from

professional literature, and sequential measurements of the patient’s condition

during treatment is encouraged to support the potential for continued

improvement that may justify the patients need for rehabilitative therapy or

the patient’s need for maintenance therapy.

• Functional information included on claims as required.

The clinician is required to document in the patient’s medical record, using

the G-codes and severity modifiers used in functional reporting, the patient’s

current, projected goal, and discharge status, as reported pursuant to

functional reporting requirements for each date of service for which the

reporting is required. See section 220.4 below for details on documenting G-

code and modifiers. NOTE: Functional reporting and its associated

documentation requirements are no longer applicable for claims or medical

records for dates of service on and after January 1, 2019. See the NOTE at

the beginning of Section 220.4 for more information.

C. Evaluation/Re-Evaluation and Plan of Care

The initial evaluation, or the plan of care including an evaluation, should document the

necessity for a course of therapy through objective findings and subjective patient self-reporting. Utilize the guidelines of the American Physical Therapy Association, the

American Occupational Therapy Association, or the American Speech-Language and

Hearing Association as guidelines, and not as policy. Only a clinician may perform an

initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a

plan of care. A clinician may include, as part of the evaluation or re-evaluation, objective

measurements or observations made by a PTA or OTA within their scope of practice, but

the clinician must actively and personally participate in the evaluation or re-evaluation.

The clinician may not merely summarize the objective findings of others or make

judgments drawn from the measurements and/or observations of others.

Documentation of the evaluation should list the conditions and complexities and, where it

is not obvious, describe the impact of the conditions and complexities on the prognosis

and/or the plan for treatment such that it is clear to the contractor who may review the

record that the services planned are appropriate for the individual.

Evaluation shall include:

• 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. In many cases, both a medical diagnosis

(obtained from a physician/NPP) and an impairment based treatment diagnosis related to

treatment are relevant. The treatment diagnosis may or may not be identified by the

therapist, depending on their scope of practice. Where a diagnosis is not allowed, use a

condition description similar to the appropriate ICD code. For example the medical

diagnosis made by the physician is CVA; however, the treatment diagnosis or condition

description for PT may be abnormality of gait, for OT, it may be hemiparesis, and for

SLP, it may be dysphagia. For PT and OT, be sure to include body part evaluated.

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;

• Results of one of the following four measurement instruments are

recommended, but not required:

National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association

Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)

Activity Measure – Post Acute Care (AM-PAC)

OPTIMAL by Cedaron through the American Physical Therapy Association

• If results of one of the four instruments above is not recorded, the record shall

contain instead the following information indicated by asterisks (*) and should

contain (but is not required to contain) all of the following, as applicable. Since

published research supports its impact on the need for treatment, information in

the following indented bullets may also be included with the results of the above

four instruments in the evaluation report at the clinician’s discretion. This

information may be incorporated into a test instrument or separately reported

within the required documentation. If it changes, update this information in the

re-evaluation, and/or treatment notes, and/or progress reports, and/or in a separate

record. When it is provided, contractors shall take this documented information

into account to determine whether services are reasonable and necessary.

Documentation supporting illness severity or complexity including, e.g.,

o Identification of other health services concurrently being provided for

this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse,

respiratory therapy, social services, psychology, nutritional/dietetic

services, radiation therapy, chemotherapy, etc.), and/ or

o Identification of durable medical equipment needed for this condition,

and/or

o Identification of the number of medications the beneficiary is taking

(and type if known); and/or

o If complicating factors (complexities) affect treatment, describe why

or how. For example: Cardiac dysrhythmia is not a condition for

which a therapist would directly treat a patient, but in some patients

such dysrhythmias may so directly and significantly affect the pace of

progress in treatment for other conditions as to require an exception to

caps for necessary services. Documentation should indicate how the

progress was affected by the complexity. Or, the severity of the

patient’s condition as reported on a functional measurement tool may

be so great as to suggest extended treatment is anticipated; and/or

o Generalized or multiple conditions. The beneficiary has, in addition to

the primary condition being treated, another disease or condition being

treated, or generalized musculoskeletal conditions, or conditions

affecting multiple sites and these conditions will directly and

significantly impact the rate of recovery; and/or.

o Mental or cognitive disorder. The beneficiary has a mental or

cognitive disorder in addition to the condition being treated that will

directly and significantly impact the rate of recovery; and/or.

o Identification of factors that impact severity including e.g., age, time

since onset, cause of the condition, stability of symptoms, how

typical/atypical are the symptoms of the diagnosed condition,

availability of an intervention/treatment known to be effective,

predictability of progress.

Documentation supporting medical care prior to the current episode, if any,

(or document none) including, e.g.,

o Record of discharge from a Part A qualifying inpatient, SNF, or home

health episode within 30 days of the onset of this outpatient therapy

episode, or

o Identification of whether beneficiary was treated for this same

condition previously by the same therapy discipline (regardless of

where prior services were furnished; and

o Record of a previous episode of therapy treatment from the same or

different therapy discipline in the past year.

Documentation required to indicate beneficiary health related to quality of

life, specifically,

o The beneficiary’s response to the following question of self-related

health: “At the present time, would you say that your health is

excellent, very good, fair, or poor?” If the beneficiary is unable to

respond, indicate why; and

Documentation required to indicate beneficiary social support including,

specifically,

o Where does the beneficiary live (or intend to live) at the conclusion of

this outpatient therapy episode? (e.g., private home, private apartment,

rented room, group home, board and care apartment, assisted living,

SNF), and

o Who does beneficiary live with (or intend to live with) at the

conclusion of this outpatient therapy episode? (e.g., lives alone,

spouse/significant other, child/children, other relative, unrelated

person(s), personal care attendant), and

o Does the beneficiary require this outpatient therapy plan of care in

order to return to a premorbid (or reside in a new) living environment,

and

o Does the beneficiary require this outpatient therapy plan of care in

order to reduce Activities of Daily Living (ADL) or Instrumental

Activities of Daily Living or (IADL) assistance to a premorbid level or

to reside in a new level of living environment (document prior level of

independence and current assistance needs); and

*Documentation required to indicate objective, measurable beneficiary

physical function including, e.g.,

o Functional assessment individual item and summary scores (and

comparisons to prior assessment scores) from commercially available

therapy outcomes instruments other than those listed above; or

o Functional assessment scores (and comparisons to prior assessment

scores) from tests and measurements validated in the professional

literature that are appropriate for the condition/function being

measured; or

o Other measurable progress towards identified goals for functioning in

the home environment at the conclusion of this therapy episode of

care.

• 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; and

• 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.

NOTE: When the Evaluation Serves as the Plan of Care. When an evaluation is the only

service provided by a provider/supplier in an episode of treatment, the evaluation serves

as the plan of care if it contains a diagnosis, or in states where a therapist may not

diagnose, a description of the condition from which a diagnosis may be determined by

the referring physician/NPP. The goal, frequency, and duration of treatment are implied

in the diagnosis and one-time service. The referral/order of a physician/NPP is the

certification that the evaluation is needed and the patient is under the care of a physician.

Therefore, when evaluation is the only service, a referral/order and evaluation are the

only required documentation. If the patient presented for evaluation without a referral or

order and does not require treatment, a physician referral/order or certification of the

evaluation is required for payment of the evaluation. A referral/order dated after the

evaluation shall be interpreted as certification of the plan to evaluate the patient.

The time spent in evaluation shall not also be billed as treatment time. Evaluation

minutes are untimed and are part of the total treatment minutes, but minutes of evaluation

shall not be included in the minutes for timed codes reported in the treatment notes.

Re-evaluations shall be included in the documentation sent to contractors when a re-evaluation has been performed. See the definition in section 220. Re-evaluations are

usually focused on the current treatment and might not be as extensive as initial

evaluations. Continuous assessment of the patient's progress is a component of ongoing

therapy services and is not payable as a re-evaluation. A re-evaluation is not a routine,

recurring service but is focused on evaluation of progress toward current goals, making a

professional judgment about continued care, modifying goals and/or treatment or

terminating services. A formal re-evaluation is covered only if the documentation

supports the need for further tests and measurements after the initial evaluation.

Indications for a re-evaluation include new clinical findings, a significant change in the

patient's condition, or failure to respond to the therapeutic interventions outlined in the

plan of care.

A re-evaluation may be appropriate prior to planned discharge for the purposes of

determining whether goals have been met, or for the use of the physician or the treatment

setting at which treatment will be continued.

A re-evaluation is focused on evaluation of progress toward current goals and making a

professional judgment about continued care, modifying goals and/or treatment or

terminating services. Reevaluation requires the same professional skills as evaluation.

The minutes for re-evaluation are documented in the same manner as the minutes for

evaluation. Current Procedural Terminology does not define a re-evaluation code for

speech-language pathology; use the evaluation code.

Plan of Care. See section 220.1.2 for requirements of the plan. The evaluation and plan

may be reported in two separate documents or a single combined document.

D. Progress Report

The progress report provides justification for the medical necessity of treatment.

Contractors shall determine the necessity of services based on the delivery of services as

directed in the plan and as documented in the treatment notes and progress report. For

Medicare payment purposes, information required in progress reports 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. It is not required that

the referring or supervising physician/NPP sign the progress reports written by a PT, OT

or SLP.

Timing. The minimum progress report period shall be at least once every 10 treatment

days. The day beginning the first reporting period is the first day of the episode of

treatment regardless of whether the service provided on that day is an evaluation, re-evaluation or treatment. Regardless of the date on which the report is actually written

(and dated), the end of the progress report period is either a date chosen by the clinician

or the 10th treatment day, whichever is shorter. The next treatment day begins the next

reporting period. The progress report period requirements are complete when both the

elements of the progress report and the clinician’s active participation in treatment have

been documented.

For example, for a patient evaluated on Monday, October 1 and being treated five times a

week, on weekdays: On October 5, (before it is required), the clinician may choose to

write a progress report for the last week’s treatment (from October 1 to October 5).

October 5 ends the reporting period and the next treatment on Monday, October 8 begins

the next reporting period. If the clinician does not choose to write a report for the next

week, the next report is required to cover October 8 through October 19, which would be

10 treatment days.

It should be emphasized that the dates for recertification of plans of care do not affect the

dates for required progress reports. (Consideration of the case in preparation for a report

may lead the therapist to request early recertification. However, each report does not

require recertification of the plan, and there may be several reports between

recertifications). In many settings, weekly progress reports are voluntarily prepared to

review progress, describe the skilled treatment, update goals, and inform physician/NPPs

or other staff. The clinical judgment demonstrated in frequent reports may help justify

that the skills of a therapist are being applied, and that services are medically necessary.

Absences. Holidays, sick days or other patient absences may fall within the progress

report period. Days on which a patient does not encounter qualified professional or

qualified personnel for treatment, evaluation or re-evaluation do not count as treatment

days. However, absences do not affect the requirement for a progress report at least once

during each progress report period. If the patient is absent unexpectedly at the end of the

reporting period, when the clinician has not yet provided the required active participation

during that reporting period, a progress report is still required, but without the clinician’s

active participation in treatment, the requirements of the progress report period are

incomplete.

Delayed Reports. If the clinician has not written a progress report before the end of the

progress reporting period, it shall be written within 7 calendar days after the end of the

reporting period. If the clinician did not participate actively in treatment during the

progress report period, documentation of the delayed active participation shall be entered

in the treatment note as soon as possible. The treatment note shall explain the reason for

the clinician’s missed active participation. Also, the treatment note shall document the

clinician’s guidance to the assistant or qualified personnel to justify that the skills of a

therapist were required during the reporting period. It is not necessary to include in this

treatment note any information already recorded in prior treatment notes or progress

reports.

The contractor shall make a clinical judgment whether continued treatment by assistants

or qualified personnel is reasonable and necessary when the clinician has not actively

participated in treatment for longer than one reporting period. Judgment shall be based

on the individual case and documentation of the application of the clinician’s skills to

guide the assistant or qualified personnel during and after the reporting period.

Early Reports. Often, progress reports are written weekly, or even daily, at the discretion

of the clinician. Clinicians are encouraged, but not required to write progress reports

more frequently than the minimum required in order to allow anyone who reviews the

records to easily determine that the services provided are appropriate, covered and

payable.

Elements of progress reports may be written in the treatment notes if the

provider/supplier or clinician prefers. If each element required in a progress report is

included in the treatment notes at least once during the progress report period, then a

separate progress report is not required. Also, elements of the progress report may be

incorporated into a revised plan of care when one is indicated. Although the progress

report written by a therapist does not require a physician/NPP signature when written as a

stand-alone document, the revised plan of care accompanied by the progress report shall

be re-certified by a physician/NPP. See section 220.1.2C, Changes to the Therapy Plan,

for guidance on when a revised plan requires certification.

Progress Reports for Services Billed Incident to a Physician’s Service. The policy for

incident to services requires, for example, the physician’s initial service, direct

supervision of therapy services, and subsequent services of a frequency which reflect

his/her active participation in and management of the course of treatment (see section

60.1B of this chapter. Also, see the billing requirements for services incident to a

physician in Pub. 100-04, chapter 26, Items 17, 19, 24, and 31.) Therefore, supervision

and reporting requirements for supervising physician/NPPs supervising staff are the same

as those for PTs and OTs supervising PTAs and OTAs with certain exceptions noted

below.

When a therapy service is provided by a therapist, supervised by a physician/NPP and

billed incident to the services of the physician/NPP, the progress report shall be written

and signed by the therapist who provides the services.

When the services incident to a physician are provided by qualified personnel who are

not therapists, the ordering or supervising physician/NPP must personally provide at least

one treatment session during each progress report period and sign the progress report.

Documenting Clinician Participation in Treatment in the Progress Report. Verification of

the clinician’s required participation in treatment during the progress report period shall

be documented by the clinician’s signature on the treatment note and/or on the progress

report. When unexpected discontinuation of treatment occurs, contractors shall not

require a clinician’s participation in treatment for the incomplete reporting period.

The Discharge Note (or Discharge Summary) is required for each episode of outpatient

treatment. In provider settings where the physician/NPP writes a discharge summary and

the discharge documentation meets the requirements of the provider setting, a separate

discharge note written by a therapist is not required. The discharge note shall be a

progress report written by a clinician, and shall cover the reporting period from the last

progress report to the date of discharge. In the case of a discharge unanticipated in the

plan or previous progress report, the clinician may base any judgments required to write

the report on the treatment notes and verbal reports of the assistant or qualified personnel.

In the case of a discharge anticipated within 3 treatment days of the progress report, the

clinician may provide objective goals which, when met, will authorize the assistant or

qualified personnel to discharge the patient. In that case, the clinician should verify that

the services provided prior to discharge continued to require the skills of a therapist, and

services were provided or supervised by a clinician. The discharge note shall include all

treatment provided since the last progress report and indicate that the therapist reviewed

the notes and agrees to the discharge.

At the discretion of the clinician, the discharge note may include additional information;

for example, it may summarize the entire episode of treatment, or justify services that

may have extended beyond those usually expected for the patient’s condition. Clinicians

should consider the discharge note the last opportunity to justify the medical necessity of

the entire treatment episode in case the record is reviewed. The record should be

reviewed and organized so that the required documentation is ready for presentation to

the contractor if requested.

Assistant’s Participation in the Progress Report. PTAs or OTAs may write elements of

the progress report dated between clinician reports. Reports written by assistants are not

complete progress reports. The clinician must write a progress report during each

progress report period regardless of whether the assistant writes other reports. However,

reports written by assistants are part of the record and need not be copied into the

clinicians report. Progress reports written by assistants supplement the reports of

clinicians and shall include:

• Date of the beginning and end of the reporting period that this report refers to;

• Date that the report was written (not required to be within the reporting period);

• Signature, and professional identification, or for dictated documentation, the

identification of the qualified professional who wrote the report and the date on which it

was dictated;

• Objective reports of the patient’s subjective statements, if they are relevant. For

example, “Patient reports pain after 20 repetitions”. Or, “The patient was not feeling well

on 11/05/06 and refused to complete the treatment session.”; and

• Objective measurements (preferred) or description of changes in status relative to

each goal currently being addressed in treatment, if they occur. Note that assistants may

not make clinical judgments about why progress was or was not made, but may report the

progress objectively. For example: “increasing strength” is not an objective

measurement, but “patient ambulates 15 feet with maximum assistance” is objective.

Descriptions shall make identifiable reference to the goals in the current plan of care.

Since only long term goals are required in the plan of care, the progress report may be

used to add, change or delete short term goals. Assistants may change goals only under

the direction of a clinician. When short term goal changes are dictated to an assistant or

to qualified personnel, report the change, clinician’s name, and date. Clinicians verify

these changes by co-signatures on the report or in the clinician’s progress report. (See

section 220.1.2(C) to modify the plan for changes in long term goals).

The evaluation and plan of care are considered incorporated into the progress report, and

information in them is not required to be repeated in the report. For example, if a time

interval for the treatment is not specifically stated, it is assumed that the goals refer to the

plan of care active for the current progress report period. If a body part is not specifically

noted, it is assumed the treatment is consistent with the evaluation and plan of care.

Any consistent method of identifying the goals may be used. Preferably, the long term

goals may be numbered (1, 2, 3,) and the short term goals that relate to the long term

goals may be numbered and lettered 1.A, 1.B, etc. The identifier of a goal on the plan of

care may not be changed during the episode of care to which the plan refers. A clinician,

an assistant on the order of a therapist or qualified personnel on the order of a

physician/NPP shall add new goals with new identifiers or letters. Omit reference to a

goal after a clinician has reported it to be met, and that clinician’s signature verifies the

change.

Content of Clinician (Therapist, Physician/NPP) Progress Reports. In addition to the

requirements above for notes written by assistants, the progress report of a clinician shall

also include:

• 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. It is also required at the time of discharge on the

discharge note or summary, as applicable. The clinician documents, on the applicable

dates of service, the specific nonpayable G-codes and severity modifiers used in the

required reporting of the patient’s functional limitation(s) on the claim for services,

including how the modifier selection was made. See subsection C of 220.4 below for

details relevant to documentation requirements.

A re-evaluation should not be required before every progress report routinely, but may be

appropriate when assessment suggests changes not anticipated in the original plan of

care.

Care must be taken to assure that documentation justifies the necessity of the services

provided during the reporting period, particularly when reports are written at the

minimum frequency. Justification for treatment must include, for example, objective

evidence or a clinically supportable statement of expectation that:

• In the case of rehabilitative therapy, the patient’s condition has the potential to

improve or is improving in response to therapy, maximum improvement is yet to

be attained; and there is an expectation that the anticipated improvement is

attainable in a reasonable and generally predictable period of time.

• In the case of maintenance therapy, treatment by the therapist is necessary to

maintain, prevent or slow further deterioration of the patient’s functional status

and the services cannot be safely carried out by the beneficiary him or herself, a

family member, another caregiver or unskilled personnel.

Objective evidence consists of standardized patient assessment instruments, outcome

measurements tools or measurable assessments of functional outcome. Use of objective

measures at the beginning of treatment, during and/or after treatment is recommended to

quantify progress and support justifications for continued treatment. Such tools are not

required, but their use will enhance the justification for needed therapy.

Example: The Plan states diagnosis is 787.2- Dysphagia secondary to other late effects

of CVA. Patient is on a restricted diet and wants to drink thick liquids. Therapy is

planned 3X week, 45 minute sessions for 6 weeks. Long term goal is to consume a

mechanical soft diet with thin liquids without complications such as aspiration

pneumonia. Short Term Goal 1: Patient will improve rate of laryngeal elevation/timing

of closure by using the super-supraglottic swallow on saliva swallows without cues on

90% of trials. Goal 2: Patient will compensate for reduced laryngeal elevation by

controlling bolus size to ½ teaspoon without cues 100%. The progress report for 1/3/06

to 1/29/06 states: 1. Improved to 80% of trials; 2. Achieved. Comments: Highly

motivated; spouse assists with practicing, compliant with current restrictions. New Goal:

“5. Patient will implement above strategies to swallow a sip of water without coughing

for 5 consecutive trials. Mary Johns, CCC-SLP, 1/29/06.” Note the provider is billing

92526 three times a week, consistent with the plan; progress is documented; skilled

treatment is documented.

E. Treatment Note

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 billing codes on the claim. Documentation is required for every treatment day, and

every therapy service. The format shall not be dictated by contractors and may vary

depending on the practice of the responsible clinician and/or the clinical setting.

The treatment note is not required to document the medical necessity or appropriateness

of the ongoing therapy services. Descriptions of skilled interventions should be included

in the plan or the progress reports and are allowed, but not required daily. Non-skilled

interventions need not be recorded in the treatment notes as they are not billable.

However, notation of non-skilled treatment or report of activities performed by the

patient or non-skilled staff may be reported voluntarily as additional information if they

are relevant and not billed. Specifics such as number of repetitions of an exercise and

other details included in the plan of care need not be repeated in the treatment notes

unless they are changed from the plan.

Documentation of each treatment shall include the following required elements:

• 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. Record each service provided that is represented by a

timed code, regardless of whether or not it is billed, because the unbilled timed services

may impact the billing; and

• 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). For Medicare purposes, it is not required that unbilled services that

are not part of the total treatment minutes be recorded, although they may be included

voluntarily to provide an accurate description of the treatment, show consistency with the

plan, or comply with state or local policies. The amount of time for each specific

intervention/modality provided to the patient may also be recorded voluntarily, but

contractors shall not require it, as it is indicated in the billing. The billing and the total

timed code treatment minutes must be consistent. See Pub. 100-04, chapter 5, section

20.2 for description of billing timed codes; and

• 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 (i.e., the signature of Kathleen Smith, PTA, with notation of phone consultation

with Judy Jones, PT, supervisor, when permitted by state and local law). The signature

and identification of the supervisor need not be on each treatment note, unless the

supervisor actively participated in the treatment. Since a clinician must be identified on

the plan of care and the progress report, the name and professional identification of the

supervisor responsible for the treatment is assumed to be the clinician who wrote the plan

or report. When the treatment is supervised without active participation by the

supervisor, the supervisor is not required to cosign the treatment note written by a

qualified professional. When the responsible supervisor is absent, the presence of a

similarly qualified supervisor on the clinic roster for that day is sufficient documentation

and it is not required that the substitute supervisor sign or be identified in the

documentation.

If a treatment is added or changed under the direction of a clinician during the treatment

days between the progress reports, the change must be recorded and justified on the

medical record, either in the treatment note or the progress report, as determined by the

policies of the provider/supplier. New exercises added or changes made to the exercise

program help justify that the services are skilled. For example: The original plan was for

therapeutic activities, gait training and neuromuscular re-education. “On Feb. 1 clinician

added electrical stim. to address shoulder pain.”

Documentation of each treatment may also include the following optional elements to be

mentioned only if the qualified professional recording the note determines they are

appropriate and relevant. If these are not recorded daily, any relevant information should

be included in the progress report.

• Patient self-report;

• Adverse reaction to intervention;

• Communication/consultation with other providers (e.g., supervising clinician,

attending physician, nurse, another therapist, etc.);

• Significant, unusual or unexpected changes in clinical status;

• Equipment provided; and/or

• Any additional relevant information the qualified professional finds

appropriate.

See Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 20.2 for

instructions on how to count minutes. It is important that the total number of timed

treatment minutes support the billing of units on the claim, and that the total treatment

time reflects services billed as untimed codes.