On August 20, 2018, I published “What Documentation is Required in a Progress Report“. Click HERE to access this article.
That article then led readers to ask me what the Centers for Medicare and Medicaid Services (CMS) and other commercial insurance carriers require in daily note documentation. In this article, I will provide the daily note documentation requirements for Medicare Part B, Cigna, several state BCBS insurance carriers, and a few state physical therapy practice acts.
Lets start with the Medicare program and what CMS requires in a daily note for outpatient therapy services paid under Part B benefits. The required elements are as follows:
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You also mentioned a Daily Note as well. Can you share the required content for a daily.
Go to my Current News page to read the articles.
In a daily note, is sets and reps required to be documented?
Also, is there any ins requirement to break down the exercises by treatment code, such as TE, NMR, or MT CPT codes?
If you are asking is there a requirement, CMS does not state this in their manual. This question would require further consultation services that would not be appropriate in this format.
Can you recommend a resource where I can learn this info? Perhaps one of your past webinars that specifically deals with this?
Also what information in a daily note is required to distinguish billing a TE vs a NMR code, is listing the specific exercise enough to satisfy the ins companies?
I would recommend you purchase and listen to this webinar: https://gawendaseminars.com/product/2019-documentation-everything-after-the-initial-evaluation-for-pt-ot-slp-part-2/