Regulatory

Therapy Documentation

Medicare requires that documentation be completed at regular intervals and include specific information.

The information documented needs to be measurable and the goals functional. It should also delineate why your professional experience and intervention are required. In addition, the JCAHO standards are another source that defines documentation requirements.

An evaluation tool must be completed prior to the initiation of skilled therapy services. Medicare does not specify the actual tool the therapy professionals are required to complete for an evaluation. Regardless of the evaluation tool, in order to support services provided the facility must produce the following information for the Medicare Administrative Contractor:

  • Physician order(s) 
  • Signed and dated certification by physician 
  • Date of evaluation 
  • Start of care date 
  • Medical diagnosis 
  • Treatment diagnosis 
  • Onset date 
  • Current level of function 
  • Prior level of function 
  • Treatment plan with long and short term goals 
  • Previous therapy administered to include: 
    • Date
    • Diagnosis for treatment 
    • Modalities administered 
  • Progress notes detailing service provided for each date of service billed 
  • Grid reflecting service/HCPCS

Weekly progress notes are required to address the specific goals devised upon evaluation or goals modified during the course of the therapy program. Weekly documentation is required to identify the patient’s progress towards goals outlined on the evaluation. This documentation supports medical necessity for ongoing intervention as well as supports the services provided. The lack of this essential documentation may lead the Medicare Administrative Contractor to determine that services are not reasonable or necessary for the beneficiary.

Progress notes are most supportive with positive and proactive language versus focusing on negative aspects of the therapy programs and reduced outcome. Listing barriers to achieving set program goals is only pertinent when the note has descriptions of steps taken to aid the patient in overcoming barriers.

The use of progress notes is the therapist’s only way to communicate to a Medicare reviewer that a patient benefited from therapy. Progress notes should contain information regarding: functional goalsevidence of skilled serviceand changes in levels of independence.

Daily notes should include evidence of skilled service and the patient’s response to the treatment. Weekly and monthly progress notes should contain all the above as well as comparative data. Medicare guidelines require that information regarding changes in level of independence be addressed at least weekly.

ABBREVIATIONS

Explanation of Abbreviations commonly used in Rehab Charting:

A
Assisted

AAROM
Active Assistive Range of Motion

Abd
Abduction

Add
Adduction

ADL
Activities Daily Living

AFO
Ankle Foot Orthosis

AKA
Above Knee Amputation

ALD
Assistive Listening Device

ALS
Anterior Lateral Sclerosis

Amb
Ambulation

AP
Active and Passive

AROM
Active Range of Motion

(B)
Both/Bilateral

BID
Two Time a Day

BKA
Below Knee Amputation

BUE
Bilateral Upper Extremity

C
Cane

c
With

COTA
Certified Occupational Therapy Assistant

CP
Cerebral Palsy

Cr Tr
Crutch Training

CVA
Cerebral Vascular Accident

SWD
Short Wave Diathermy

Dx
Diagnosis

ES
Electrical Stimulation

Eval
Evaluation

EXT
Extension

Ext Rot
External Rotation

FLEX
Flexion

Funct Act
Functional Activities

FWB
Full Weight Bearing

Fx
Fracture

HP
Hot Packs

Hx
History

I
Independent

Int Rot
Internal Rotation

IR
Infra Red

KAFO
Knee Ankle Foot Orthosis

L
Left

LB
Low Back

LBQC
Large Based Quad Cane

LE
Lower Extremity

LLC
Long Leg Cast

LLE
Left Lower Extremity

LS
Lumbosacral

LTG
Long Term Goals

LUE
Left Upper Extremity

MD
Muscular Dystrophy

MG
Myasthenia Gravis

MS
Multiple Sclerosis

Max
Maximal

Min
Minimal

Mod
Moderate

MW
Microwave

NA
Not Applicable

BQC
Narrow Based Quad Cane

NPO
Nothing Orally

NS
No Show

NT
Not Tested

ORIF
Open Reduction Internal Fixation

OTR
Occupational Therapist Registered

OT
Occupational Therapy

PRE
Progressive Resistive Exercise

p
Post/After

PROM
Passive Range of Motion

PT
Physical Therapy/Therapist

PTA
Physical Therapy Assistant

Pt
Patient

PU Walker
Pick Up Walker

PWB
Partial Weight Bearing

QD
Daily

R
Right

Rehab
Rehabilitation

RLE
Right Lower Extremity

RNA
Restorative Nursing Aide

ROM
Range of Motion

RUE
Right Upper Extremity

RW
Rolling Walker

Rx
Treatment

S
Supervised

s
Without

SBA
Stand By Assist

SBQC
Small Based Quad Cane

Sdly
Side Living

Sev
Severe

Sh
Shoulder

SLC
Short Leg Cast

SLP
Speech Language Pathologist

SOB
Short of Breath

SSW
Social Service Worker

ST
Speech Therapy

STG
Short-Term Goals

TENS
Transcutaneous Electrical Neural Stimulation

THA
Total Hip Arthroplasty

THR
Total Hip Replacement

TIA
Transient Ischemic Attack

TIW
3 Times a Week

TKR
Total Knee Replacement

TTWB
Toe Touch Weight Bearing

Tx
Traction

tx
Treatment

UE
Upper Extremity

US
Ultra Sound

UV
Ultra Violet

W
Walker

WBAT
Weight Bearing As Tolerated

WC
Wheelchair

WFL
Within Functional Limits

WNF
Within Normal Limits

WP
Whirlpool

Up arrow
Increase

Down arrow
Decrease

OCCUPATIONAL THERAPY NARRATIVE PROGRESS NOTES

OCCUPATIONAL THERAPY WEEKLY NOTE

OCCUPATIONAL THERAPY MONTHLY SUMMARY & RECERTIFICATION

PHYSICAL THERAPY NARRATIVE PROGRESS NOTES

PHYSICAL THERAPY WEEKLY NOTE

PHYSICAL THERAPY MONTHLY SUMMARY & RECERTIFICATION

SPEECH THERAPY NARRATIVE PROGRESS NOTES

SPEECH-LANGUAGE PATHOLOGY THERAPY WEEKLY NOTE

SPEECH-LANGUAGE PATHOLOGY THERAPY MONTHLY SUMMARY & RECERTIFICATION

PROGRESS FLOW SHEETS SAMPLE

NARRATIVE PROGRESS NOTES SAMPLE

COMMONLY DENIED TREATMENTS

  1. Activities and exercises to promote overall improvement, general conditioning or endurance without a specific functional gain.
  2. Exercise and activities which can be administered by non-skilled persons.
  3. Duplicating services as when two disciplines provide the same treatment for the same reason.
  4. General range of motion exercise not related to a specific, measured loss of function that can be regained with therapy.
  5. Group treatment with group goals and not specific individual treatment goals.
  6. Hot packs without any other modality or procedure, commonly referred to as “feel good” hot packs.
  7. Limited learning potential for the stated goals.
  8. Long term maintenance therapy without the training of caregivers to continue with a program.
  9. Poor or fair rehabilitation potential. The lowest potential allowable is “Good for goals as stated”.
  10. Ongoing routine training in self care after initial instruction period and improved skills have been taught.
  11. Passive range of motion without any other procedure or modality.
  12. Repetitive services or treatment with no measured progress.
  13. Routine self care training and mobility where self care function would return spontaneously and safely without a skilled therapist.
  14. Routine assistance with ambulation that can be performed by an unskilled person.
  15. Therapy evaluations and treatment for rehabilitation candidates without the potential to achieve stated goals.
  16. Reevaluations unless a significant change has occurred.
  17. Treatment of degenerative, chronic or old (more than six months) onset diagnoses where no functional potential exists.
  18. Treatments rendered without a physician’s order.
  19. Where poor cognitive status would prohibit new learning or adequate participation in the therapy process for the stated goals.
  20. When treatment is unsubstantiated with specific and measurable baseline evaluation information.