Checklist: Therapy and rehabilitation services documentation
This checklist is intended to provide health care providers with a reference for use when responding to medical
documentation requests for therapy and rehabilitation services. Health care providers retain responsibility to submit
complete and accurate documentation.
Note: To print and include this checklist with your medical documentation, click the print button at the end of this
form. Documentation requirements.
Documentation requirements
Documentation is for the correct date of service billed.
Documentation is for the correct beneficiary billed.
Documentation contains a valid and legible signature of performing provider
Documentation should include signature logs or signature attestations if applicable
Documentation must be legible, relevant and sufficient to justify the medical necessity of services billed.
Documentation must include the Initial evaluation for the episode of treatment under review. That contains
all the required components outlined in Pub 100-02, Chapter 15, Section 220.3C
Documentation to support medical necessity including that the services are skilled, rehabilitative services,
provided by clinicians (or qualified professionals when appropriate) with the approval of a
physician/nonphysician practitioner (NPP), safe, and effective (e.g., progress indicates that the care is
effective in rehabilitation of function).
Documentation must indicate that the patient is under the care of a physician, nonphysician practitioner, or
optometrist for the presenting diagnosis. (See comprehensive outpatient rehabilitation facility (CORF)
guidelines specific to CORFs.)
Documentation must include a plan of care that shall contain, at minimum the diagnosis, long term treatment
goals; and the type, amount, duration and frequency of therapy services. Additional info as required by
regulation may be found at 42 CFR 424.24, 410.61, and 410.105© (for CORFs) See Pub. 100-02, Chapter
15, section 220.3 for further documentation requirements.
Documentation must contain long term goals and the goals should be measurable and pertain to identified
functional impairments. Therapists typically also establish short term goals, such as goals for a week or
month of therapy, to help track progress toward the goal for the episode of care.
Documentation should provide the type of treatment to be provided such as physical therapy (PT),
occupational therapy (OT), or speech language pathology (SLP), or, where appropriate, the type may be a
description of a specific treatment or intervention. Where a physician/NPP establishes a plan, the plan must
specify the type (PT, OT, SLP) of therapy planned.
Documentation must include a separate plan of care for each type of therapy discipline. When more than
one discipline is treating a patient, each must establish a diagnosis, goals, etc. independently. However, the
form of the plan and the number of plans incorporated into one document are not limited as long as the
required information is present and related to each discipline separately.
Documentation must include Initial certification and any applicable re-certification per requirements outlined
in Pub 100-02, Chapter 15, Section 220.1.3 A-D and LCD
Documentation of treatment encounter notes/treatment logs as outlined in Pub 100-02, Chapter 15, Section
220.3E. 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 must include all applicable 10
th
visits progress notes written by the clinician. While only a
specific date of service is under review remember if the note for that date of service cannot support medical
necessity alone please include any documentation for prior dates that support the medical necessity of the
service date billed.
