Overview of Documentation for Medicare Outpatient Therapy Services

On this page:

• Things to Remember
• Summary
• Evaluation/Re-Evaluation
• Plan of Care/Certification of the Plan of Care
• Progress Reports
• Treatment Notes
• Discharge Note
• Resources

Things to Remember

• Documentation may not be reviewed by a speech-language pathologist (SLP) employed by Medicare or its contractors. Descriptions of the rational for and outcomes of care should be clearly communicated to avoid unnecessary denials.
• Don't assume that the reviewer will understand why the service requires the skill of an SLP. Your documentation should clearly illustrate medical necessity and provide additional information that the reviewer may need.
• Include objective measures of the patient's improvement in your documentation to justify therapy services.
• It is imperative that SLPs ensure that documentation is legible, relevant, and sufficient to justify the services billed.

Summary

In general, Medicare requires that therapy 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.
• Establish through objective measurements that the patient is making progress toward goals. CMS realizes that regression and plateaus can happen during treatment, and recommends that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.

Medicare requires that the patient’s medical record include documentation of a) the evaluation, b) plan of care (POC), c) daily treatment notes, d) progress report(s), and e) discharge note. This information is not submitted with the claim but must be supplied to the Medicare Administrative Contractor (MAC) when requested as part of an audit, unless otherwise specified. 

Evaluation/Re-Evaluation

Evaluation

The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings. 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 so that it is clear to a reviewer that the services planned are appropriate for the individual.

An 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. The treatment diagnosis may or may not be identified by the therapist, depending on their scope of practice. Where a diagnosis is not allowed, CMS advises the use of a condition description similar to the appropriate ICD-10 code.
• Results of ASHA's national outcomes measurement system (optional). Additional information can be found on the NOMS section of the ASHA website.
• If NOMS is not used, the record shall contain documentation to indicate objective, measurable beneficiary physical function including, for example,
  1. 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
  2. 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
  3. Other measurable progress towards identified goals for functioning in the home environment at the conclusion of this therapy episode of care.
• Additional optional documentation that further substantiates medical necessity is included in the manual [PDF].

When an evaluation is the only service provided 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 or nonphysician practitioner (NPP). An NPP includes a physician assistant, nurse practitioner, or clinical nurse specialist, as allowed under state law and regulation. The goal, frequency, intensity 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. 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.

Re-Evaluation

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. Re-evaluation requires the same professional skills as evaluation.

Current Procedural Terminology (CPT®) codes do not define a re-evaluation code for speech-language pathology; clinicians should use the appropriate evaluation code to report a re-evaluation on the claim.

Plan of Care/Certification of the Plan of Care

Medicare does not require an order/referral for therapy services but if an order/referral has been provided it should be maintained in the medical record to further substantiate medical necessity. Medicare coverage instead is associated with the physician/NPP’s certification of the plan of care (POC). However, as described in more detail below, if an order/referral is received separately, initial certification of the plan of care is not required. A physician/NPP must recertify a plan of care periodically.

The POC shall be consistent with the related evaluation. The evaluation and plan may be reported in two separate documents or a single combined document.

Long term treatment goals should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care. The POC shall contain, at minimum, the following information:

• Diagnoses;
• Long term treatment goals; and
• Type, amount, duration, and frequency of therapy services.

The amount of treatment refers to the number of times in a day the type of treatment will be provided. The frequency refers to the number of times in a week the type of treatment is provided. The duration is the number of weeks, or the number of treatment sessions.

Certification of the POC can be accomplished in one of two ways:

1. In instances when the patient has a signed and dated order/referral from a physician/NPP, the therapist does not need them to separately certify the POC. The therapist must still send the physician/NPP the plan and maintain documentation the POC was sent (e.g. snail mail delivery confirmation, fax confirmation sheet); or
2. If there is not an order/referral, the POC must be certified (signed) by the physician/NPP within 30 days of its development.

The POC must be recertified by the physician/NPP (even with there is an order/referral available) every 90 days or at the end of the initial certification period, whichever is less. For example, if the POC was certified for 45 days and an additional two weeks of therapy is required, the recertification must happen at the end of the 45 days. Recertification is also required when the therapist modifies the POC at any point during the episode.

Delayed Certification

Delayed certification and recertification requirements will be considered satistified when, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay. Certifications are acceptable without justification for 30 days after they are due.

Delayed certification should include one or more certifications or recertifications on a single signed and dated document. Delayed certifications should include any evidence the provider or supplier considers necessary to justify the delay. For example, a certification may be delayed because the physician/NPP did not sign it, or the original was lost. In the case of a long delay in certification (over 6 months), the provider or supplier may choose to submit another form of documentation (e.g., an order, progress notes, telephone contact, requests for certification or signed statement of a physician/NPP) with the delayed certification indicating the need for care and that the patient was under the care of a physician/NPP at the time of the treatment. The MAC may request such documentation for delayed certifications if it is required for review.

The intent is to avoid stopping or denying needed therapy when certification is delayed. The delayed certification of otherwise covered services should be accepted unless the MAC has reason to believe that there was no physician/NPP involved in the patient’s care or treatment did not meet the patient’s need (and therefore, the certification was signed inappropriately).

Progress Reports

The progress report provides justification for the medical necessity of treatment. A clinician must complete a progress report at least once every 10 treatment days. The beginning of 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.

Progress notes should contain:

• An 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.

Documentation should justify the necessity of the services provided during the reporting period, and include, for example, objective evidence or a clinically supportable statement of expectation that 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.

Objective evidence consists of standardized patient assessment instruments, outcome measurements tools, or measurable assessments of functional outcome such as NOMS. 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.

CMS Example of a SLP Progress Note:

The POC states diagnosis is 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

1. 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.
2. Goal 2: Patient will compensate for reduced laryngeal elevation by controlling bolus size to ½ teaspoon without cues 100%.

The Progress Report for 1/3/25 to 1/29/25 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, 1/29/25."

Note the provider is billing 92526 three times a week, consistent with the plan; progress is documented; skilled treatment is documented.

Treatment Notes

The purpose of these notes is to create a record of all treatments and skilled interventions that are provided and to record the time of the services. Clear documentation of treatment notes also helps to justify the billing codes reported on the claim. Documentation is required for every treatment day, every therapy service, and must include the following information:

• Date of treatment;
• Identification of each specific intervention/modality provided and billed for both timed and untimed codes. Use language that can be compared with the billing on the claim to verify correct coding;
• Total treatment time in minutes. It is especially important to capture total treatment time when billing a timed CPT code. Total treatment time does not include time for services that are not billable (e.g., rest periods, discussion with the caregiver). 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; 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.

If a treatment is added or changed between the progress note intervals, the change must be recorded and justified in the medical record. Frequent professional judgments resulting in upgrades to the patient's activity show skilled treatment. Objective measurement showing improvement is also helpful.

If there is no improvement, the clinicians should provide information to explain the setbacks, illness, new condition, or social circumstances that are impeding progress and why it is believed that progress is still attainable.

Discharge Note

The discharge note is required and is a progress report written by a clinician and covering the reporting period from the last progress report to the date of discharge. The discharge note must include all treatment provided since the last progress report and indicate that the therapist reviewed the notes and agrees to the 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

Resources

• Section 220.3 of Chapter 15 of the Medicare Beneficiary Policy Manual [PDF]
• ASHA's Practice Portal on Documentation in Health Care