Documentation Requirements for PT/OT services

1.    All documentation must be maintained in the patient's medical record and available to the contractor upon request.
2.    Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
3.    The submitted medical record must support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code must describe the service performed.
4.    The medical record documentation must support the medical necessity of the services as directed in this policy.
5.    This documentation should establish the variables that influence the patient's condition, especially those factors that influence the clinician's decision to provide more servcies than are typical for the individual's condition.
6.    Documentation should establish through objective measurements that the patient is making progress toward goals. Results of one of the following four measurements are recommended:
o    National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association.
o    Patient Inquiry by Focus on Therapeutic Outcomes, Inc. (FOTO).
o    Activity Measure - Post Acute Care (AM-PAC).
o    OPTIMAL by Cedaron through the American Physical Therapy Association.
Note: If results of one of the four instruments listed above are not recorded, the medical record shall contain that information outlined in Pub. 100-02, Chapter 15, Section 220.3.
7.    The medical record must identify the physician responsible for the general medical care.
8.    Therapy services must be furnished according to a written treatment plan determined by the physician or by the therapist who will provide the treatment after an appropriate assessment of the condition (illness or injury). All qualified professionals rendering therapy must document the appropriate history, examination, diagnosis, functional assessment, type of treatment, the body areas to be treated, the date therapy was initiated, and expected frequency and number of treatments.
9.    Outpatient therapy MUST be under the care of a Physician/NPP. An order (sometimes called a referral) for therapy service, documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.
10.    Certification is the physician's/NPP's approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. A certification is timely when it is obtained within 30 calendar days of the initial treatment under that plan of care.
11.    Recertifications must be obtained within the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whichever is less.
12.    For CMS recommendations regarding progress reports and modifications to the plan of care, refer to the Medicare Benefit Policy Manual Pub. 100-02, Chapter 15.
13.    When a verbal order is used to certify the plan of care, a dated notation should be made in the patient's medical record.
14.    Evidence considered necessary to justify delayed certification should be maintained by the supplier of services.
15.    Signature and professional identity of the person who established the plan and the date it was established must be recorded with the plan.
16.    Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time or the need to establish a safe and effective maintenance program. Evaluation, re-evaluation and assessment documented in Progress Notes should describe objective measurements that, when compared, show improvement in function or decrease in severity or rationalization for an optimistic outlook to justify continued treatment.
17.    When both a modality/procedure and an evaluation service are billed, the evaluation may be reimbursed if the medical necessity for the evaluation is clearly documented. Allowed unit limitations (once per provider, per discipline, per date of service, per patient) by discipline for CPT codes included in this LCD are described in the “Utilization Guidelines” section below.
18.    When therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other “incident to” requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings.
19.    Documentation supporting the medical necessity for multiple heating modalities (codes 97018, 97024, 97034) on the same date of service must be available for review and show that all were needed toward the restoration of function.
20.    The total number of timed minutes must be documented in the medical record.

Medicare covers the following number of therapy services without routinely requiring medical review of records to determine medical necessity:
•    Five (15 minutes each) timed PT services per patient per day.
•    Five (15 minutes each) timed OT services per patient per day.
•    Sixty (15 minutes each) PT services per patient per month.
•    Sixty (15 minutes each) OT services per patient per month.

Providers of PT/OT services must be aware, however, that any service reported to Medicare, even when reported at a frequency within the following stated covered guidelines, may be denied if done so in association with medical review of the patient's record that demonstrates no medical necessity for the services. Similarly, services in addition to the above limits may be payable when done so in association with medical review of the patient's record that demonstrates medical necessity for additional services.

Likewise, providers of PT/OT services must understand that although Medicare will allow the following units of service, each service must be medically reasonable and necessary for the specific patient and their condition. Additionally, Medicare expects that the patient's medical record will clearly demonstrate that medical necessity. Further, Medicare does not expect that maximum allowable services will be routinely necessary, necessary for multiple-week periods, or necessary for the entirety of the patient's course of treatment.

Any federally established financial limitations on outpatient therapy services' coverage and coding rules will apply.