Therapy Treatment Note Requirement for Inpatient SNF Services

The Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-2, Medicare Benefit Policy Manual, Chapter 15 is the primary source for therapy documentation instructions.

The manual (CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.B.) states, “Specific policies may differ by setting. Other policies concerning therapy services are found in other manuals. When a therapy service policy is specific to a setting, it takes precedence over these general outpatient policies. For special rules on:

• CORFs - See CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 12 of this manual and also CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5;
• SNF - See CMS IOM Publication 100-02, Chapter 8 of this manual and also CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 6, for SNF claims/billing;
• HHA - See CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7 of this manual, and CMS IOM Publication 100-04, Medicare claims Processing Manual, Chapter 10;
• Group Therapy and Students - See CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 230;
• Arrangements - CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 10.3;
• Coverage descriptions - See CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.5.1; and
• Therapy caps - See CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10.2, for a complete description of this financial limitation.”

Regardless if a daily therapy service is provided in a SNF, CORF, IRF, HHA or outpatient program, thorough documentation must be submitted to support the type of therapy services provided and billed according to CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.

The issue of “specificity” of what is required to support therapy services billed meet Medicare’s definition of daily skilled service being provided is addressed in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Section 220.15.E. The manual states, in relevant part, “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 MAC should not “dictate” the format of the report. The therapist can provide the treatment note in any format, as long as it provides “sufficient documentation” (42 CFR) for the services provided.

The manual requires the documentation be provided for "every treatment day" to "justify the use of the billing codes." "Descriptions of the skilled interventions should be included in the plan or the progress reports and are allowed."

Revised 7/1/2024