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Medicare Documentation Requirements for PT

Medicare documentation requirements for physical therapy could vary from state to state, and you should review them with your local Medicare office. Because documentation is the most important factor in getting paid from Medicare, there are things to consider as you begin.

  1. Physician Order

    • The physician's orders or prescription is by far the most important piece of documentation you will need. You must get a signed and dated order from the doctor for physical therapy. Check with your local Medicare office about the use of stamped signatures, as some states will not accept a prescription that includes one.

    Initial Evaluation

    • The first visit with the patient should be for an initial evaluation. This visit will be lengthier than the others as the patient will need to provide more information. There will need to be documentation with all appropriate medical history, including previous physical therapy. The evaluation should include both subjective and objective measures and state the plan of treatment.

    Plan of Care

    • The treatment plan should include several of the same measures as the initial evaluation. This should state the overall plan for treatment, including the amount and frequency as well as the diagnosis of the patient. In most states, the plan of care must include a signature from the prescribing physician, redone at specific intervals.

    Progress Notes

    • Every physical therapy visit will need to have a corresponding progress note. It should include each exercise performed as well as the frequency, the repetitions, and the equipment used. When a cancellation of a visit occurs, the doctor will need to include a progress report as well. Progress reports are very important in the case of Medicare audits, as this is how they determine the type of care received as well as patient progress to justify payment.

    Discharge Summary

    • Upon completion of physical therapy treatment, a discharge summary stating the reason for discharge and the progress or lack of progress made will need to be in the patient's file. It will also need a signature from the referring physician filed with the patient's treatment records.

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