Therapy Checklist

NGS would like to thank all providers for their cooperation in providing requested medical records to the Comprehensive Error Rate Testing (CERT) Documentation Contractor (CDC). We at NGS appreciate your effort and encourage your continued assistance in the program.

While the response rates to CDC requests for medical records have increased, NGS would like to offer some additional information to help decrease therapy denials due to submission of insufficient documentation.

When billing outpatient therapy services to Medicare, providers must have documentation to support the medical necessity of the therapy services. In addition, documentation must identify each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding. Documentation requirements for Medicare outpatient therapy services can be found in the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.3. (1 MB)

Complete medical record documentation is the key to allowing fair review for Medicare payment of therapy services. The following information provides an informational checklist of the documentation that should be submitted to support the interventions billed to Medicare. When a ‘Medical Records Request’ is received from the CERT contractor or from the NGS Medical Review Department, please refer to the following suggested documentation checklist.

Therapy Documentation Checklist

• Initial evaluation including treatment plan/reevaluations
• Certification/recertification (physician or NPP approval of the plan of care) related to the service dates of the claim reviewed*
• Progress reports since onset of therapy
  • At a minimum, progress reports must be completed by the clinician once every ten visits or once every 30 calendar days, whichever is less
• Treatment notes (daily notes) and, if completed, exercise/activity logs
  • Must include total timed code treatment minutes and total treatment time in minutes, in addition to identification of the interventions provided
• Discharge note, if completed

* A certification, which is required for Medicare payment, is the physician’s or NPP's approval of the therapy plan of care. The certification acknowledges not only that the patient is or will be receiving therapy, but also that the physician/NPP is aware of the type of therapy that will be occurring (including amount, frequency and duration) and for what purpose (goals). The approval of the plan of care is what makes the certification different than an order or a referral (unless the order/referral includes a plan of care).

Revised: 9/2016
Original posted date: 1/2009