• Incomplete or Inaccurate Documentation

    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.

    Importance of Documentation

    Office of the Inspector General Video: Importance of Documentation  

    Common Issues With Outpatient Physical Therapy Documentation

    The Medicare program has identified several common issues with outpatient physical therapy documentation that result in improper payments. They include:

    • Missing or incomplete plan of care
    • Missing physician or nonphysician practitioner (NPP) signatures and dates
    • Missing total time for procedures and modalities
    • Missing certification and recertification of plan of care

    Top 10 Payer Complaints about Documentation (Reasons for Denials)

    1. Poor legibility
    2. Incomplete documentation
    3. No documentation for date of service
    4. Abbreviations – too many, cannot understand
    5. Documentation does not support the billing (coding)
    6. Does not demonstrate skilled care
    7. Does not support medical necessity
    8. Does not demonstrate progress or maintenance of function if that is the stated goal
    9. Repetitious daily notes showing no change in patient status
    10. Interventions with no clarification of time, frequency, duration

    Best Practices

    See the Documentation page under the Best Practices section for resources you can use to improve your documentation.

  • Last Updated: 3/15/2019
    Contact: advocacy@apta.org