Physical Therapy Services

Insufficient Documentation Causes Most Improper Payments. Insufficient documentation means something was missing from the medical records. Below is a list of the most common reasons CERT determined there was insufficient documentation that caused improper payments for physical therapy:

Missing initial evaluation
Missing initial signed and dated plan of care
Missing updated signed and dated plan of care
Missing progress report
Missing time spent for the therapy services
Missing electronic signature or legible signature of the performing provider

Initial evaluation: The initial evaluation should document the necessity of a course of therapy through objective findings.

Individualized plan of care: The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated short and long-term goals. The plan of care must be signed and dated by the performing and ordering provider.

Updated plan of care: The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated short and long-term goals. The plan of care must be signed and dated by the performing and ordering provider.

Progress report: A progress report period shall be at least once every ten treatments.

Time: The total treatment time includes the minutes for the timed code treatment and untimed code treatment.

Signature: An electronic signature or legible signature is required on all notes.

For more information on outpatient physical and occupational therapy, see LCD for Outpatient Physical and Occupational Therapy Services (L33631). The medical policies and related articles can be found on our Medical Policies web page.

Physical Therapy Services

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