What Documentation is Required in a Daily Note

September 3, 2018
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Rick Gawenda
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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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This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.