Documenting Therapy and Rehabilitation Services

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