What Documentation is Required in a Progress Report

August 20, 2018
Rick Gawenda

I am often asked what the Centers for Medicare and Medicaid Services (CMS) and other private insurance carriers require in terms of documentation in a progress report. In this article, I will provide the progress note documentation requirements for Medicare Part B, Cigna and several state BCBS insurance carriers.

Lets start with the Medicare program and what CMS requires in a progress report for outpatient therapy services paid under Part B benefits. The required elements are as follows:

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  1. What is the difference between a progress report and a reassessment?
    Also, what are the acceptable time intervals for documenting progress notes or reassessments?

    1. Some insurance carriers and state practice acts use the terms interchangeably. You would need to check to see how they are defining reassessment and what is required. How often a Progress Report is required is what you would have to check with the insurance carrier or your state practice act.

  2. Thank you for this information! The title said “what is required in a daily treatment note”. When reading the article the title says “whats required in a progress note”. Can you give information on what is required in a daily treatment note?

  3. What documentation is required in the treatment flow sheet? Are there specific items that need to be included?

  4. What is the interval requirement for progress notes for medicare? I recently had a discussion with other therapist from around the country that said Medicare did away with the 30 day requirement and only require progress notes to be done every 10th visit when reporting updated FL codes.

  5. In the outpatient setting how should the following be handled and would the progress note type be sufficient? Scenario: when you have a current POC for LBP and patient now presents with new complaint of left shoulder pain and that will now be added for treatment along with the LBP? Should a new evaluation note be done or is it sufficient to add to the progress note along with the separate treatment note. And how should this be billed? Would it be as a new evaluation code for the new body part? Along with the therapy codes for the day?

    1. That is not a question I can answer in this forum. If interested in consulting services, please email me directly.

  6. Our organization completes pre-operative evaluations for many of our TKR and THR patients. In many cases, these patient receive an evaluation and treatment at the initial visit and do not return to therapy again until after their surgery. In this scenario, what documentation needs to be completed? I realize for a Medicare patient, we will need to complete an evaluation and a POC since treatment was provided. Do we also need to complete a daily therapy note and also a discharge summary for these patients?
    Thank you.

    1. Most insurance carriers, including the Medicare program, do not knowingly pay for Pre-operative evaluations. I would question if this should even be billed to the Medicare program.

      1. Rick,
        I probably did not explain this well. We refer to these as “pre-op joint assessments’, but these are referrals sent to us with a diagnosis of OA which are candidates for TJR based on physician evaluation. Some continue on with therapy and avoid surgery while others fail and undergo TJR surgery. In these cases, surgery is not a definite and the surgery is not scheduled prior to this evaluation. The ones I am referring to above do not wish to continue with therapy and ask to continue their therapy at home or at at a gym. Some do not tolerate their exercises well and schedule their surgery post evaluation. In these cases, what documentation do we need to complete? An Evaluation, POC, daily note, and a discharge summary seem to be a lot to complete for a 1 time visit. Thank you for your help.

        1. Upon your clarification, it sounds as if you are doing prehab and this could be considered skilled PT services. Whether a 1-time only visit or the patient attends several sessions, all of Medicare’s documentation, coding and billing would apply. For a 1-time only visit, a separate DC report would not be required as this should be documented in the plan of care in the initial evaluation that it’s a 1-time only visit.

  7. When managing a patient for a new condition with a new Rx in place. Is it acceptable to bill an IE, without having a formal DC written. More specifically if you were seeing this patient for a cervical condition, did not write up a formal DC, and this patient is happy with the progress for the neck. If this patient wants to commence tx for a lumbar condition, is it acceptable to perform an IE and bill IE without a formal DC note?

    1. The Medicare program, many private insurance carriers and many state practice acts require that the therapist complete a DC report, regardless of whether the patient actually attended their last scheduled appointment. Keep in mind that the medical record is a legal document and could end up in a court of law along with the therapist.

  8. Does a progress note need to be signed by a physician if not establishing a new POC? For example the POC is for 90 days and we are doing a progress note at 30 days but not changing the original POC.