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:
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.
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 in our Medical Policy Center.
Posted 4/2/2018
