Documenting Therapy and Rehabilitation Services

July 15, 2014
Rick Gawenda

The CERT A/B MAC Outreach & Education Task Force, a partnership of all A/B Medicare Administrative Contractors, has created a guide to educate providers on common documentation errors for outpatient rehabilitation therapy services. These widespread errors contribute to Medicare’s national payment error rate, as measured by the Comprehensive Error Rate Testing (CERT) program. The guide also discusses contents for a plan of care, signature and certification of the plan of care, treatment note, and functional reporting requirements.

The leading cause of payment errors for therapy services is

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  1. What is the preferred method to document timed codes, untimed codes and total time for therapy sessions?
    Would documenting total billable time be sufficient when submitting billing of timed and untimed codes?