Documenting Therapy and Rehabilitation Services

April 18, 2014
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Rick Gawenda
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First Coast Service Options, Medicare Administrative Contractor for the state of Florida, has published a guide to educate providers on common documentation errors for outpatient rehabilitation therapy services. The leading cause of payment errors for therapy is insufficient documentation in the medical records. In the guide, First Coast discusses issues with the contents of the plan of care, signature and certification requirements for the plan of care, daily note documentation, and functional limitation reporting. Even though this guide was published by First Coast for the state of Florida, the guide would be beneficial to all therapists who treat Medicare outpatients in any setting and in any state. To access the guide, click

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