Example #5 describes a scenario where a patient on a maintenance program needs

intermittent review and possibly a new or revised maintenance program.

EXAMPLE: A patient who has a progressive degenerative disease is performing

the activities in a maintenance program established by a therapist with the
assistance of family members. The program needs to be re-evaluated to
determine whether assistive equipment is needed and to establish a new or revised
maintenance program to maintain function or to prevent or slow further
deterioration. Intermittent re-evaluation of the maintenance program would
generally be covered as this is a service that requires the skills of a therapist.
Should the therapist conducting the re-evaluation determine that the program
needs to be revised, these services would generally be covered.

Maintenance program services that do not meet the criteria of this section are not
reasonable or necessary and are not covered under §1862(a)(1)(A) of the Act.

The maintenance program provisions outlined in this section do not apply to the PT, OT,
or SLP services furnished in a comprehensive outpatient rehabilitation facility (CORF)
because the statute specifies that CORF services are rehabilitative.

220.3 - Documentation Requirements for Therapy Services

(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)

A. General

To be payable, the medical record and the information on the claim form must
consistently and accurately report covered therapy services, as documented in the medical
record. Documentation must be legible, relevant and sufficient to justify the services
billed. In general, services must be covered therapy services provided according to
Medicare requirements. Medicare requires that the services billed be supported by
documentation that justifies payment. Documentation must comply with all requirements
applicable to Medicare claims.

The documentation guidelines in sections 220 and 230 of this chapter identify the
minimal expectations of documentation by providers or suppliers or beneficiaries
submitting claims for payment of therapy services to the Medicare program. State or
local laws and policies, or the policies or professional guidelines of the relevant
profession, the practice, or the facility may be more stringent. It is encouraged but not
required that narratives that specifically justify the medical necessity of services be
included in order to support approval when those services are reviewed. (See also section
220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services)

Contractors shall consider the entire record when reviewing claims for medical necessity
so that the absence of an individual item of documentation does not negate the medical
necessity of a service when the documentation as a whole indicates the service is
necessary. Services are medically necessary if the documentation indicates they meet the
requirements for medical necessity including that they are skilled, rehabilitative services,
provided by clinicians (or qualified professionals when appropriate) with the approval of
a physician/NPP, safe, and effective (i.e., progress indicates that the care is effective in
rehabilitation of function).

B. Documentation Required

List of required documentation. These types of documentation of therapy services are

expected to be submitted in response to any requests for documentation, unless the
contractor requests otherwise. The timelines are minimum requirements for Medicare
payment. Document as often as the clinician’s judgment dictates but no less than the
frequency required in Medicare policy:

• Evaluation and Plan of Care (may be one or two documents). Include the initial
evaluation and any re-evaluations relevant to the episode being reviewed;

• Certification (physician/NPP approval of the plan) and recertifications when

records are requested after the certification/recertification is due. See definitions in
section 220 and certification policy in section 220.1.3 of this chapter. Certification (and
recertification of the plan when applicable) are required for payment and must be
submitted when records are requested after the certification or recertification is due.

• Progress Reports (including Discharge Notes, if applicable) when records are

requested after the reports are due. (See definitions in section 220 and descriptions in
220.3 D);

• Treatment notes for each treatment day (may also serve as progress reports when
required information is included in the notes);

• A separate justification statement may be included either as a separate document

or within the other documents if the provider/supplier wishes to assure the contractor
understands their reasoning for services that are more extensive than is typical for the
condition treated. A separate statement is not required if the record justifies treatment
without further explanation.

Limits on Requirements. Contractors shall not require more specific documentation

unless other Medicare manual policies require it. Contractors may request further
information to be included in these documents concerning specific cases under review
when that information is relevant, but not submitted with records.

Dictated Documentation. For Medicare purposes, dictated therapy documentation is

considered completed on the day it was dictated. The qualified professional may edit and
electronically sign the documentation at a later date.

Dates for Documentation. The date the documentation was made is important only to
establish the date of the initial plan of care because therapy cannot begin until the plan is
established unless treatment is performed or supervised by the same clinician who
establishes the plan. However, contractors may require that treatment notes and progress
reports be entered into the record within 1 week of the last date to which the progress
report or treatment note refers. For example, if treatment began on the first of the month
at a frequency of twice a week, a progress report would be required at the end of the
month. Contractors may require that the progress report that describes that month of
treatment be dated not more than 1 week after the end of the month described in the
report.

Document Information to Meet Requirements. In preparing records, clinicians must be

familiar with the requirements for covered and payable outpatient therapy services. For
example, the records should justify:

• The patient is under the care of a physician/NPP;

Physician/NPP care shall be documented by physician/NPP certification

(approval) of the plan of care; and

Although not required, other evidence of physician/NPP involvement in the

patient’s care may include, for example: order/referral, conference, team
meeting notes, and correspondence.

• Services require the skills of a therapist.

Services must not only be provided by the qualified professional or qualified

personnel, but they must require, for example, the expertise, knowledge,
clinical judgment, decision making and abilities of a therapist that assistants,
qualified personnel, caretakers or the patient cannot provide independently. A
clinician may not merely supervise, but must apply the skills of a therapist by
actively participating in the treatment of the patient during each progress
report period. In addition, a therapist’s skills may be documented, for
example, by the clinician’s descriptions of their skilled treatment, the changes
made to the treatment due to a clinician’s assessment of the patient’s needs on
a particular treatment day or changes due to progress the clinician judged
sufficient to modify the treatment toward the next more complex or difficult
task.

• Services are of appropriate type, frequency, intensity and duration for the
individual needs of the patient.

Documentation should establish the variables that influence the patient’s

condition, especially those factors that influence the clinician’s decision to
provide more services than are typical for the individual’s condition.

Clinicians and contractors shall determine typical services using published

professional literature and professional guidelines. The fact that services are
 typically billed is not necessarily evidence that the services are typically
appropriate. Services that exceed those typically billed should be carefully
documented to justify their necessity, but are payable if the individual patient
benefits from medically necessary services. Also, some services or episodes
of treatment should be less than those typically billed, when the individual
patient reaches goals sooner than is typical.

Documentation should establish through objective measurements that the

patient is making progress toward goals. Note that regression and plateaus
can happen during treatment. It is recommended that the reasons for lack of
progress be noted and the justification for continued treatment be documented
if treatment continues after regression or plateaus.

Needs of the Patient. When a service is reasonable and necessary, the patient
also needs the services. Contractors determine the patient’s needs through
knowledge of the individual patient’s condition, and any complexities that
impact that condition, as described in documentation (usually in the
evaluation, re-evaluation, and progress report). Factors that contribute to need
vary, but in general they relate to such factors as the patient’s diagnoses,
complicating factors, age, severity, time since onset/acuity, self-
efficacy/motivation, cognitive ability, prognosis, and/or medical,
psychological and social stability. Changes in objective and sometimes to
subjective measures of improvement also help establish the need for
rehabilitative services. The use of scientific evidence, obtained from
professional literature, and sequential measurements of the patient’s condition
during treatment is encouraged to support the potential for continued
improvement that may justify the patients need for rehabilitative therapy or
the patient’s need for maintenance therapy.

• Functional information included on claims as required.

The clinician is required to document in the patient’s medical record, using

the G-codes and severity modifiers used in functional reporting, the patient’s
current, projected goal, and discharge status, as reported pursuant to
functional reporting requirements for each date of service for which the
reporting is required. See section 220.4 below for details on documenting G-
code and modifiers. NOTE: Functional reporting and its associated
documentation requirements are no longer applicable for claims or medical
records for dates of service on and after January 1, 2019. See the NOTE at
the beginning of Section 220.4 for more information.

C. Evaluation/Re-Evaluation and Plan of Care

The initial evaluation, or the plan of care including an evaluation, should document the
necessity for a course of therapy through objective findings and subjective patient self-
reporting. Utilize the guidelines of the American Physical Therapy Association, the
American Occupational Therapy Association, or the American Speech-Language and
Hearing Association as guidelines, and not as policy. Only a clinician may perform an
initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a
plan of care. A clinician may include, as part of the evaluation or re-evaluation, objective
measurements or observations made by a PTA or OTA within their scope of practice, but
the clinician must actively and personally participate in the evaluation or re-evaluation.
The clinician may not merely summarize the objective findings of others or make
judgments drawn from the measurements and/or observations of others.

Documentation of the evaluation should list the conditions and complexities and, where it
is not obvious, describe the impact of the conditions and complexities on the prognosis
and/or the plan for treatment such that it is clear to the contractor who may review the
record that the services planned are appropriate for the individual.

Evaluation shall include:

• A diagnosis (where allowed by state and local law) and description of the specific
problem(s) to be evaluated and/or treated. The diagnosis should be specific and as
relevant to the problem to be treated as possible. In many cases, both a medical diagnosis
(obtained from a physician/NPP) and an impairment based treatment diagnosis related to
treatment are relevant. The treatment diagnosis may or may not be identified by the
therapist, depending on their scope of practice. Where a diagnosis is not allowed, use a
condition description similar to the appropriate ICD code. For example the medical
diagnosis made by the physician is CVA; however, the treatment diagnosis or condition
description for PT may be abnormality of gait, for OT, it may be hemiparesis, and for
SLP, it may be dysphagia. For PT and OT, be sure to include body part evaluated.
Include all conditions and complexities that may impact the treatment. A description
might include, for example, the premorbid function, date of onset, and current function;

• Results of one of the following four measurement instruments are

recommended, but not required:

National Outcomes Measurement System (NOMS) by the American Speech-

Language Hearing Association

Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)

Activity Measure – Post Acute Care (AM-PAC)

OPTIMAL by Cedaron through the American Physical Therapy Association

• If results of one of the four instruments above is not recorded, the record shall
contain instead the following information indicated by asterisks (*) and should
contain (but is not required to contain) all of the following, as applicable. Since
published research supports its impact on the need for treatment, information in
the following indented bullets may also be included with the results of the above
four instruments in the evaluation report at the clinician’s discretion. This
information may be incorporated into a test instrument or separately reported
within the required documentation. If it changes, update this information in the
re-evaluation, and/or treatment notes, and/or progress reports, and/or in a separate
record. When it is provided, contractors shall take this documented information
into account to determine whether services are reasonable and necessary.

Documentation supporting illness severity or complexity including, e.g.,

o Identification of other health services concurrently being provided for

this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse,
respiratory therapy, social services, psychology, nutritional/dietetic
services, radiation therapy, chemotherapy, etc.), and/ or

o Identification of durable medical equipment needed for this condition,

and/or

o Identification of the number of medications the beneficiary is taking

(and type if known); and/or

o If complicating factors (complexities) affect treatment, describe why

or how. For example: Cardiac dysrhythmia is not a condition for
which a therapist would directly treat a patient, but in some patients
such dysrhythmias may so directly and significantly affect the pace of
progress in treatment for other conditions as to require an exception to
caps for necessary services. Documentation should indicate how the
progress was affected by the complexity. Or, the severity of the
patient’s condition as reported on a functional measurement tool may
be so great as to suggest extended treatment is anticipated; and/or

o Generalized or multiple conditions. The beneficiary has, in addition to

the primary condition being treated, another disease or condition being
treated, or generalized musculoskeletal conditions, or conditions
affecting multiple sites and these conditions will directly and
significantly impact the rate of recovery; and/or.

o Mental or cognitive disorder. The beneficiary has a mental or

cognitive disorder in addition to the condition being treated that will
directly and significantly impact the rate of recovery; and/or.

o Identification of factors that impact severity including e.g., age, time

since onset, cause of the condition, stability of symptoms, how
typical/atypical are the symptoms of the diagnosed condition,
availability of an intervention/treatment known to be effective,
predictability of progress.
Documentation supporting medical care prior to the current episode, if any,
(or document none) including, e.g.,

o Record of discharge from a Part A qualifying inpatient, SNF, or home

health episode within 30 days of the onset of this outpatient therapy
episode, or

o Identification of whether beneficiary was treated for this same

condition previously by the same therapy discipline (regardless of
where prior services were furnished; and

o Record of a previous episode of therapy treatment from the same or

different therapy discipline in the past year.

Documentation required to indicate beneficiary health related to quality of

life, specifically,

o The beneficiary’s response to the following question of self-related

health: “At the present time, would you say that your health is
excellent, very good, fair, or poor?” If the beneficiary is unable to
respond, indicate why; and

Documentation required to indicate beneficiary social support including,

specifically,

o Where does the beneficiary live (or intend to live) at the conclusion of
this outpatient therapy episode? (e.g., private home, private apartment,
rented room, group home, board and care apartment, assisted living,
SNF), and

o Who does beneficiary live with (or intend to live with) at the
conclusion of this outpatient therapy episode? (e.g., lives alone,
spouse/significant other, child/children, other relative, unrelated
person(s), personal care attendant), and

o Does the beneficiary require this outpatient therapy plan of care in

order to return to a premorbid (or reside in a new) living environment,
and

o Does the beneficiary require this outpatient therapy plan of care in

order to reduce Activities of Daily Living (ADL) or Instrumental
Activities of Daily Living or (IADL) assistance to a premorbid level or
to reside in a new level of living environment (document prior level of
independence and current assistance needs); and
 *Documentation required to indicate objective, measurable beneficiary
physical function including, e.g.,

o Functional assessment individual item and summary scores (and

comparisons to prior assessment scores) from commercially available
therapy outcomes instruments other than those listed above; or

o Functional assessment scores (and comparisons to prior assessment

scores) from tests and measurements validated in the professional
literature that are appropriate for the condition/function being
measured; or

o Other measurable progress towards identified goals for functioning in

the home environment at the conclusion of this therapy episode of
care.

• Clinician’s clinical judgments or subjective impressions that describe the current

functional status of the condition being evaluated, when they provide further information
to supplement measurement tools; and

• A determination that treatment is not needed, or, if treatment is needed a

prognosis for return to premorbid condition or maximum expected condition with
expected time frame and a plan of care.

NOTE: When the Evaluation Serves as the Plan of Care. When an evaluation is the only
service provided by a provider/supplier in an episode of treatment, the evaluation serves
as the plan of care if it contains a diagnosis, or in states where a therapist may not
diagnose, a description of the condition from which a diagnosis may be determined by
the referring physician/NPP. The goal, frequency, and duration of treatment are implied
in the diagnosis and one-time service. The referral/order of a physician/NPP is the
certification that the evaluation is needed and the patient is under the care of a physician.
Therefore, when evaluation is the only service, a referral/order and evaluation are the
only required documentation. If the patient presented for evaluation without a referral or
order and does not require treatment, a physician referral/order or certification of the
evaluation is required for payment of the evaluation. A referral/order dated after the
evaluation shall be interpreted as certification of the plan to evaluate the patient.

The time spent in evaluation shall not also be billed as treatment time. Evaluation
minutes are untimed and are part of the total treatment minutes, but minutes of evaluation
shall not be included in the minutes for timed codes reported in the treatment notes.

Re-evaluations shall be included in the documentation sent to contractors when a re-

evaluation has been performed. See the definition in section 220. Re-evaluations are
usually focused on the current treatment and might not be as extensive as initial
evaluations. Continuous assessment of the patient's progress is a component of ongoing
therapy services and is not payable as a re-evaluation. A re-evaluation is not a routine,
recurring service but is focused on evaluation of progress toward current goals, making a
professional judgment about continued care, modifying goals and/or treatment or
terminating services. A formal re-evaluation is covered only if the documentation
supports the need for further tests and measurements after the initial evaluation.
Indications for a re-evaluation include new clinical findings, a significant change in the
patient's condition, or failure to respond to the therapeutic interventions outlined in the
plan of care.

A re-evaluation may be appropriate prior to planned discharge for the purposes of

determining whether goals have been met, or for the use of the physician or the treatment
setting at which treatment will be continued.

A re-evaluation is focused on evaluation of progress toward current goals and making a

professional judgment about continued care, modifying goals and/or treatment or
terminating services. Reevaluation requires the same professional skills as evaluation.
The minutes for re-evaluation are documented in the same manner as the minutes for
evaluation. Current Procedural Terminology does not define a re-evaluation code for
speech-language pathology; use the evaluation code.

Plan of Care. See section 220.1.2 for requirements of the plan. The evaluation and plan
may be reported in two separate documents or a single combined document.

D. Progress Report

The progress report provides justification for the medical necessity of treatment.

Contractors shall determine the necessity of services based on the delivery of services as
directed in the plan and as documented in the treatment notes and progress report. For
Medicare payment purposes, information required in progress reports shall be written by
a clinician that is, either the physician/NPP who provides or supervises the services, or by
the therapist who provides the services and supervises an assistant. It is not required that
the referring or supervising physician/NPP sign the progress reports written by a PT, OT
or SLP.

Timing. The minimum progress report period shall be at least once every 10 treatment
days. The day beginning the first reporting period is the first day of the episode of
treatment regardless of whether the service provided on that day is an evaluation, re-
evaluation or treatment. Regardless of the date on which the report is actually written
(and dated), the end of the progress report period is either a date chosen by the clinician
or the 10th treatment day, whichever is shorter. The next treatment day begins the next
reporting period. The progress report period requirements are complete when both the
elements of the progress report and the clinician’s active participation in treatment have
been documented.

For example, for a patient evaluated on Monday, October 1 and being treated five times a
week, on weekdays: On October 5, (before it is required), the clinician may choose to
write a progress report for the last week’s treatment (from October 1 to October 5).
October 5 ends the reporting period and the next treatment on Monday, October 8 begins
the next reporting period. If the clinician does not choose to write a report for the next
week, the next report is required to cover October 8 through October 19, which would be
10 treatment days.

It should be emphasized that the dates for recertification of plans of care do not affect the
dates for required progress reports. (Consideration of the case in preparation for a report
may lead the therapist to request early recertification. However, each report does not
require recertification of the plan, and there may be several reports between
recertifications). In many settings, weekly progress reports are voluntarily prepared to
review progress, describe the skilled treatment, update goals, and inform physician/NPPs
or other staff. The clinical judgment demonstrated in frequent reports may help justify
that the skills of a therapist are being applied, and that services are medically necessary.

Absences. Holidays, sick days or other patient absences may fall within the progress
report period. Days on which a patient does not encounter qualified professional or
qualified personnel for treatment, evaluation or re-evaluation do not count as treatment
days. However, absences do not affect the requirement for a progress report at least once
during each progress report period. If the patient is absent unexpectedly at the end of the
reporting period, when the clinician has not yet provided the required active participation
during that reporting period, a progress report is still required, but without the clinician’s
active participation in treatment, the requirements of the progress report period are
incomplete.

Delayed Reports. If the clinician has not written a progress report before the end of the
progress reporting period, it shall be written within 7 calendar days after the end of the
reporting period. If the clinician did not participate actively in treatment during the
progress report period, documentation of the delayed active participation shall be entered
in the treatment note as soon as possible. The treatment note shall explain the reason for
the clinician’s missed active participation. Also, the treatment note shall document the
clinician’s guidance to the assistant or qualified personnel to justify that the skills of a
therapist were required during the reporting period. It is not necessary to include in this
treatment note any information already recorded in prior treatment notes or progress
reports.

The contractor shall make a clinical judgment whether continued treatment by assistants
or qualified personnel is reasonable and necessary when the clinician has not actively
participated in treatment for longer than one reporting period. Judgment shall be based
on the individual case and documentation of the application of the clinician’s skills to
guide the assistant or qualified personnel during and after the reporting period.

Early Reports. Often, progress reports are written weekly, or even daily, at the discretion
of the clinician. Clinicians are encouraged, but not required to write progress reports
more frequently than the minimum required in order to allow anyone who reviews the
records to easily determine that the services provided are appropriate, covered and
payable.

Elements of progress reports may be written in the treatment notes if the

provider/supplier or clinician prefers. If each element required in a progress report is
included in the treatment notes at least once during the progress report period, then a
separate progress report is not required. Also, elements of the progress report may be
incorporated into a revised plan of care when one is indicated. Although the progress
report written by a therapist does not require a physician/NPP signature when written as a
stand-alone document, the revised plan of care accompanied by the progress report shall
be re-certified by a physician/NPP. See section 220.1.2C, Changes to the Therapy Plan,
for guidance on when a revised plan requires certification.

Progress Reports for Services Billed Incident to a Physician’s Service. The policy for
incident to services requires, for example, the physician’s initial service, direct
supervision of therapy services, and subsequent services of a frequency which reflect
his/her active participation in and management of the course of treatment (see section
60.1B of this chapter. Also, see the billing requirements for services incident to a
physician in Pub. 100-04, chapter 26, Items 17, 19, 24, and 31.) Therefore, supervision
and reporting requirements for supervising physician/NPPs supervising staff are the same
as those for PTs and OTs supervising PTAs and OTAs with certain exceptions noted
below.

When a therapy service is provided by a therapist, supervised by a physician/NPP and

billed incident to the services of the physician/NPP, the progress report shall be written
and signed by the therapist who provides the services.

When the services incident to a physician are provided by qualified personnel who are
not therapists, the ordering or supervising physician/NPP must personally provide at least
one treatment session during each progress report period and sign the progress report.

Documenting Clinician Participation in Treatment in the Progress Report. Verification of

the clinician’s required participation in treatment during the progress report period shall
be documented by the clinician’s signature on the treatment note and/or on the progress
report. When unexpected discontinuation of treatment occurs, contractors shall not
require a clinician’s participation in treatment for the incomplete reporting period.

The Discharge Note (or Discharge Summary) is required for each episode of outpatient
treatment. In provider settings where the physician/NPP writes a discharge summary and
the discharge documentation meets the requirements of the provider setting, a separate
discharge note written by a therapist is not required. The discharge note shall be a
progress report written by a clinician, and shall cover the reporting period from the last
progress report to the date of discharge. In the case of a discharge unanticipated in the
plan or previous progress report, the clinician may base any judgments required to write
the report on the treatment notes and verbal reports of the assistant or qualified personnel.
In the case of a discharge anticipated within 3 treatment days of the progress report, the
clinician may provide objective goals which, when met, will authorize the assistant or
qualified personnel to discharge the patient. In that case, the clinician should verify that
the services provided prior to discharge continued to require the skills of a therapist, and
services were provided or supervised by a clinician. The discharge note shall include all
treatment provided since the last progress report and indicate that the therapist reviewed
the notes and agrees to the discharge.

At the discretion of the clinician, the discharge note may include additional information;
for example, it may summarize the entire episode of treatment, or justify services that
may have extended beyond those usually expected for the patient’s condition. Clinicians
should consider the discharge note the last opportunity to justify the medical necessity of
the entire treatment episode in case the record is reviewed. The record should be
reviewed and organized so that the required documentation is ready for presentation to
the contractor if requested.

Assistant’s Participation in the Progress Report. PTAs or OTAs may write elements of
the progress report dated between clinician reports. Reports written by assistants are not
complete progress reports. The clinician must write a progress report during each
progress report period regardless of whether the assistant writes other reports. However,
reports written by assistants are part of the record and need not be copied into the
clinicians report. Progress reports written by assistants supplement the reports of
clinicians and shall include:

• Date of the beginning and end of the reporting period that this report refers to;

• Date that the report was written (not required to be within the reporting period);

• Signature, and professional identification, or for dictated documentation, the

identification of the qualified professional who wrote the report and the date on which it
was dictated;

• Objective reports of the patient’s subjective statements, if they are relevant. For
example, “Patient reports pain after 20 repetitions”. Or, “The patient was not feeling well
on 11/05/06 and refused to complete the treatment session.”; and

• Objective measurements (preferred) or description of changes in status relative to

each goal currently being addressed in treatment, if they occur. Note that assistants may
not make clinical judgments about why progress was or was not made, but may report the
progress objectively. For example: “increasing strength” is not an objective
measurement, but “patient ambulates 15 feet with maximum assistance” is objective.

Descriptions shall make identifiable reference to the goals in the current plan of care.
Since only long term goals are required in the plan of care, the progress report may be
used to add, change or delete short term goals. Assistants may change goals only under
the direction of a clinician. When short term goal changes are dictated to an assistant or
to qualified personnel, report the change, clinician’s name, and date. Clinicians verify
these changes by co-signatures on the report or in the clinician’s progress report. (See
section 220.1.2(C) to modify the plan for changes in long term goals).

The evaluation and plan of care are considered incorporated into the progress report, and
information in them is not required to be repeated in the report. For example, if a time
interval for the treatment is not specifically stated, it is assumed that the goals refer to the
plan of care active for the current progress report period. If a body part is not specifically
noted, it is assumed the treatment is consistent with the evaluation and plan of care.

Any consistent method of identifying the goals may be used. Preferably, the long term
goals may be numbered (1, 2, 3,) and the short term goals that relate to the long term
goals may be numbered and lettered 1.A, 1.B, etc. The identifier of a goal on the plan of
care may not be changed during the episode of care to which the plan refers. A clinician,
an assistant on the order of a therapist or qualified personnel on the order of a
physician/NPP shall add new goals with new identifiers or letters. Omit reference to a
goal after a clinician has reported it to be met, and that clinician’s signature verifies the
change.

Content of Clinician (Therapist, Physician/NPP) Progress Reports. In addition to the

requirements above for notes written by assistants, the progress report of a clinician shall
also include:

• Assessment of improvement, extent of progress (or lack thereof) toward each

goal;

• Plans for continuing treatment, reference to additional evaluation results, and/or

treatment plan revisions should be documented in the clinician’s progress report; and

• Changes to long or short term goals, discharge or an updated plan of care that is
sent to the physician/NPP for certification of the next interval of treatment.

• Functional documentation is required as part of the progress report at the end of

each progress reporting period. It is also required at the time of discharge on the
discharge note or summary, as applicable. The clinician documents, on the applicable
dates of service, the specific nonpayable G-codes and severity modifiers used in the
required reporting of the patient’s functional limitation(s) on the claim for services,
including how the modifier selection was made. See subsection C of 220.4 below for
details relevant to documentation requirements.

A re-evaluation should not be required before every progress report routinely, but may be
appropriate when assessment suggests changes not anticipated in the original plan of
care.

Care must be taken to assure that documentation justifies the necessity of the services
provided during the reporting period, particularly when reports are written at the
minimum frequency. Justification for treatment must include, for example, objective
evidence or a clinically supportable statement of expectation that:

• In the case of rehabilitative therapy, the patient’s condition has the potential to
improve or is improving in response to therapy, maximum improvement is yet to
be attained; and there is an expectation that the anticipated improvement is
attainable in a reasonable and generally predictable period of time.

• In the case of maintenance therapy, treatment by the therapist is necessary to

maintain, prevent or slow further deterioration of the patient’s functional status
and the services cannot be safely carried out by the beneficiary him or herself, a
family member, another caregiver or unskilled personnel.

Objective evidence consists of standardized patient assessment instruments, outcome

measurements tools or measurable assessments of functional outcome. Use of objective
measures at the beginning of treatment, during and/or after treatment is recommended to
quantify progress and support justifications for continued treatment. Such tools are not
required, but their use will enhance the justification for needed therapy.

Example: The Plan states diagnosis is 787.2- Dysphagia secondary to other late effects
of CVA. Patient is on a restricted diet and wants to drink thick liquids. Therapy is
planned 3X week, 45 minute sessions for 6 weeks. Long term goal is to consume a
mechanical soft diet with thin liquids without complications such as aspiration
pneumonia. Short Term Goal 1: Patient will improve rate of laryngeal elevation/timing
of closure by using the super-supraglottic swallow on saliva swallows without cues on
90% of trials. Goal 2: Patient will compensate for reduced laryngeal elevation by
controlling bolus size to ½ teaspoon without cues 100%. The progress report for 1/3/06
to 1/29/06 states: 1. Improved to 80% of trials; 2. Achieved. Comments: Highly
motivated; spouse assists with practicing, compliant with current restrictions. New Goal:
“5. Patient will implement above strategies to swallow a sip of water without coughing
for 5 consecutive trials. Mary Johns, CCC-SLP, 1/29/06.” Note the provider is billing
92526 three times a week, consistent with the plan; progress is documented; skilled
treatment is documented.

E. Treatment Note

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 is required for every treatment day, and
every therapy service. The format shall not be dictated by contractors and may vary
depending on the practice of the responsible clinician and/or the clinical setting.

The treatment note is not required to document the medical necessity or appropriateness
of the ongoing therapy services. Descriptions of skilled interventions should be included
in the plan or the progress reports and are allowed, but not required daily. Non-skilled
interventions need not be recorded in the treatment notes as they are not billable.
However, notation of non-skilled treatment or report of activities performed by the
patient or non-skilled staff may be reported voluntarily as additional information if they
are relevant and not billed. Specifics such as number of repetitions of an exercise and
other details included in the plan of care need not be repeated in the treatment notes
unless they are changed from the plan.

Documentation of each treatment shall include the following required elements:

• Date of treatment; and

• Identification of 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. Record each service provided that is represented by a
timed code, regardless of whether or not it is billed, because the unbilled timed services
may impact the billing; and

• Total timed code treatment minutes and total treatment time in minutes. Total
treatment time includes the minutes for timed code treatment and untimed code
treatment. Total treatment time does not include time for services that are not billable
(e.g., rest periods). For Medicare purposes, it is not required that unbilled services that
are not part of the total treatment minutes be recorded, although they may be included
voluntarily to provide an accurate description of the treatment, show consistency with the
plan, or comply with state or local policies. The amount of time for each specific
intervention/modality provided to the patient may also be recorded voluntarily, but
contractors shall not require it, as it is indicated in the billing. The billing and the total
timed code treatment minutes must be consistent. See Pub. 100-04, chapter 5, section
20.2 for description of billing timed codes; and

• Signature and professional identification of the qualified professional who

furnished or supervised the services and a list of each person who contributed to that
treatment (i.e., the signature of Kathleen Smith, PTA, with notation of phone consultation
with Judy Jones, PT, supervisor, when permitted by state and local law). The signature
and identification of the supervisor need not be on each treatment note, unless the
supervisor actively participated in the treatment. Since a clinician must be identified on
the plan of care and the progress report, the name and professional identification of the
supervisor responsible for the treatment is assumed to be the clinician who wrote the plan
or report. When the treatment is supervised without active participation by the
supervisor, the supervisor is not required to cosign the treatment note written by a
qualified professional. When the responsible supervisor is absent, the presence of a
similarly qualified supervisor on the clinic roster for that day is sufficient documentation
and it is not required that the substitute supervisor sign or be identified in the
documentation.

If a treatment is added or changed under the direction of a clinician during the treatment
days between the progress reports, the change must be recorded and justified on the
medical record, either in the treatment note or the progress report, as determined by the
policies of the provider/supplier. New exercises added or changes made to the exercise
program help justify that the services are skilled. For example: The original plan was for
therapeutic activities, gait training and neuromuscular re-education. “On Feb. 1 clinician
added electrical stim. to address shoulder pain.”

Documentation of each treatment may also include the following optional elements to be
mentioned only if the qualified professional recording the note determines they are
appropriate and relevant. If these are not recorded daily, any relevant information should
be included in the progress report.

• Patient self-report;

• Adverse reaction to intervention;

• Communication/consultation with other providers (e.g., supervising clinician,

attending physician, nurse, another therapist, etc.);

• Significant, unusual or unexpected changes in clinical status;

• Equipment provided; and/or

• Any additional relevant information the qualified professional finds

appropriate.

See Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 20.2 for
instructions on how to count minutes. It is important that the total number of timed
treatment minutes support the billing of units on the claim, and that the total treatment
time reflects services billed as untimed codes.

220.4 – Functional Reporting

(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)

NOTE: In the calendar year (CY) 2019 Physician Fee Schedule (PFS) final rule, CMS-1693-
F, after consideration of stakeholder comments for burden reduction, a review of all of the
requirements under section 3005(g) of Middle Class Tax Relief and Jobs Creation Act of
2012 (MCTRJCA), and in light of the statutory amendments to section 1833(g) of the Act,
via section 50202 of Bipartisan Budget Act of 2018 to repeal the therapy caps, CMS
concluded that continued collection of functional reporting data through the same or reduced
format would not yield additional information to inform future analyses or to serve as a basis
for reforms to the payment system for therapy services. To reduce the burden of reporting
for providers of therapy services, the CY 2019 PFS final rule ended the requirements of
reporting the functional limitation nonpayable HCPCS G-codes and severity modifiers on
claims for therapy services and the associated documentation requirements in medical
records, effective for dates of service on and after January 1, 2019. The rule also revised
regulation text at 42 CFR 410.59, 410.60, 410.61, 410.62, 410.105, accordingly.
The instructions below apply only to dates of service when the functional reporting
requirements were effective, January 1, 2013 through December 31, 2018.

A. Selecting the G-codes to Use in Functional Reporting.

There are 42 functional G-codes, 14 sets of three codes each, for that can be used in
identifying the functional limitation being reported. Six of the G-code sets are generally
for PT and OT functional limitations and eight sets of G-codes are for SLP functional
limitations. (For a list of these codes and descriptors, see Pub. 100-04, Medicare Claims
Processing Manual, chapter 5, section 10.6 F.)

Only one functional limitation shall be reported at a time. Consequently, the clinician
must select the G-code set for the functional limitation that most closely relates to the
primary functional limitation being treated or the one that is the primary reason for
treatment. When the beneficiary has more than one functional limitation, the clinician
may need to make a determination as to which functional limitation is primary. In these
cases, the clinician may choose the functional limitation that is:

• Most clinically relevant to a successful outcome for the beneficiary;

• The one that would yield the quickest and/or greatest functional progress; or

• The one that is the greatest priority for the beneficiary.

In all cases, this primary functional limitation should reflect the predominant limitation
that the furnished therapy services are intended to address.

For services typically reported as PT or OT, the clinician reports one of the “Other
PT/OT” functional G-codes sets to report when one of the four PT/OT categorical code
sets does not describe the beneficiary’s functional limitation, as follows:

• a beneficiary’s functional limitation that is not defined by one of the four

categories;

• a beneficiary whose therapy services are not intended to treat a functional

limitation; or

• a beneficiary’s functional limitation where an overall, composite, or other score

from a functional assessment tool is used and does not clearly represent a
functional limitation defined by one of the above four categorical PT/OT code
sets.

In addition, the subsequent “Other PT/OT” G-code set is only reported after the primary
“Other PT/OT” G-code set has been reported for the beneficiary during the same episode
of care.
 For services typically reported as SLP services, the clinician uses the “Other SLP”
functional G-code to report when the functional limitation being treated is not represented
by one of the seven categorical SLP functional measures. In addition, the “Other SLP”
G-code set is used to report where an overall, composite, or other score from an
assessment tool that does not clearly represent a functional limitation defined by one of
the seven categorical SLP measures.

B. Selecting the severity modifiers to use in functional reporting/documenting.

Each G-code requires one of the following severity modifiers. When the clinician reports
any of the following a modifier is used to convey the severity of the functional limitation:
current status, the goal status and the discharge status.

Modifier Impairment Limitation Restriction

CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent impaired, limited or restricted
CJ At least 20 percent but less than 40 percent impaired, limited or restricted
CK At least 40 percent but less than 60 percent impaired, limited or restricted
CL At least 60 percent but less than 80 percent impaired, limited or restricted
CM At least 80 percent but less than 100 percent impaired, limited or restricted
CN 100 percent impaired, limited or restricted

The severity modifier reflects the beneficiary’s percentage of functional impairment as

determined by the clinician furnishing the therapy services for each functional status:
current, goal, or discharge. In selecting the severity modifier, the clinician:

• Uses the severity modifier that reflects the score from a functional assessment tool
or other performance measurement instrument, as appropriate.

• Uses his/her clinical judgment to combine the results of multiple measurement

tools used during the evaluative process to inform clinical decision making to
determine a functional limitation percentage.

• Uses his/her clinical judgment in the assignment of the appropriate modifier.

• Uses the CH modifier to reflect a zero percent impairment when the therapy
services being furnished are not intended to treat (or address) a functional
limitation.

In some cases the modifier will be the same for current status and goal status. For
example: where improvement is expected but it is not expected to be enough to move to
another modifier, such as from 10 percent to 15 percent, the same severity modifier
would be used in reporting the current and goal status. Also, when the clinician does not
expect improvement, such as for individuals receiving maintenance therapy, the modifier
used for projected goal status will be the same as the one for current status. In these
cases, the discharge status may also include the same modifier.
Therapists must document in the medical record how they made the modifier selection so
that the same process can be followed at succeeding assessment intervals.

C. Documentation of G-code and Severity Modifier Selection.

Documentation of the nonpayable G-codes and severity modifiers regarding functional

limitations reported on claims must be included in the patient’s medical record of therapy
services for each required reporting. (See Pub. 100-04, Medicare Claims Processing
Manual, chapter 5, section 10.6 for details about the functional reporting requirements on
claims for therapy services, including PT, OT, and SLP services furnished in CORFs.)

Documentation of functional reporting in the medical record of therapy services must be

completed by the clinician furnishing the therapy services:

• The qualified therapist furnishing the therapy services

• The physician/NPP personally furnishing the therapy services

• The qualified therapist furnishing services incident to the physician/NPP

• The physician/NPP for incident to services furnished by qualified personnel, who

are not qualified therapists.

The qualified therapist furnishing the PT, OT, or SLP services in a CORF.

230 - Practice of Physical Therapy, Occupational Therapy, and Speech-

Language Pathology
(Rev. 63, Issued: 12-29-06, Effective: 01-01-07, Implementation: on or before 01-29-
07)

A. Group Therapy Services. Contractors pay for outpatient physical therapy services
(which includes outpatient speech-language pathology services) and outpatient
occupational therapy services provided simultaneously to two or more individuals by a
practitioner as group therapy services (97150). The individuals can be, but need not be
performing the same activity. The physician or therapist involved in group therapy
services must be in constant attendance, but one-on-one patient contact is not required.

B. Therapy Students

1. General

Only the services of the therapist can be billed and paid under Medicare Part B. The
services performed by a student are not reimbursed even if provided under “line of sight”
supervision of the therapist; however, the presence of the student “in the room” does not
make the service unbillable. Pay for the direct (one-to-one) patient contact services of