Medicare Releases Guide on Common Therapy Documentation Errors

March 13, 2014

The Centers for Medicare & Medicaid Services (CMS) Comprehensive Error Rate Testing (CERT) Medicare Administrative Contractor (MAC) Outreach and Education Task Force distributed a guide to help therapy providers understand and avoid common documentation errors for outpatient rehabilitation therapy services. The most common error noted is that the documentation is missing the required elements.

  • Missing or illegible signature on the plan of care of the therapist or physician
  • Missing signature in narrative
  • Missing treatment minutes in narrative

The resource provides requirements for the plan of care, treatment notes, and functional reporting, along with links to the Medicare Benefit Policy Manual sections that discuss those items. In addition, the guide includes tips to improve documentation.

  • Ensure the records provide proof the service was certified and rendered
  • Ensure the records provide justification of medical necessity and skilled services
  • Ensure the plan of care is complete and the signatures are legible and dated
  • Document changes to the plan of care, including justification
  • Confirm the plan of care has been certified by the physician with a legible signature and date
  • Clearly document the total time spent in treatment


The CMS MACs have recently united to educate providers and suppliers on common issues regarding claim errors. The collaboration has resulted in a formal group, the CERT A/B MAC Outreach & Education Task Force, which will provide consistent information and help reduce claim errors. This new partnership affords providers the benefit of a collaborative, consistent voice to reduce costly claim denials as well as the CERT error rate. To sign up for updates, check with your regional MAC for details.

ASHA Resources

For more information, contact a member of ASHA's Health Care Economics and Advocacy Team at

ASHA Corporate Partners