Complete and accurate documentation of physical therapist level of evaluation and services is important to show the process of clinical reasoning and the medical necessity of the services provided to help ensure patient safety, and to justify payment of services. Insufficient and improper documentation are red flags for government and private payers that there may have been an improper payment, and they give payers cause for further scrutiny of a provider’s billing practices.
Office of the Inspector General Video: Importance of Documentation
The Medicare program has identified several common issues with outpatient physical therapy documentation that result in improper payments. They include:
See the Documentation page under the Best Practices section for resources you can use to improve your documentation.
Last Updated: 3/15/2019