Who Writes Progress Reports Under Medicare Part B
I am often asked if physical therapist assistants (PTAs) or occupational therapy assistants (OTAs) can write the progress report that is required by the Centers for Medicare and Medicaid Services (CMS) at least once every 10 visits for Medicare beneficiaries receiving outpatient therapy services. CMS is very clear on their answer regarding this question.
According to CMS, the required progress report
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Can PTAs/COTAs write elements of the Clinician’s Progress Note? Subjective comments and objective measurements?
No!
Can you confirm that the PTA/COTA is able to take measurements such as ROM, Strength, etc. (“elements of the progress report dated between clinician reports”) and then the therapist create the progress report utilizing these measurements?
An assistant can perform ROM measurements and MMT. Please read the section highlighted in the article for all the progress report requirements.
Are COTA/PTA allowed to write DC recommendations? Are they able to clear an acute care inpatient for discharge if goals set by the OT/PT are met? This is in particular for the state of Florida.
Thank you
You would need to check the Florida state practice act for PT and OT to see what they are or are not allowed to do.
Rick
Thank you this is very helpful. Do you know if the PTA is able to sign a daily treatment note in the state of Michigan, or per Medicare guidelines. I tend to stick with Medicare ruling.
The Medicare program does not require notes written by a PTA or an OTA. You also have to check your state practice act. If your practice act requires it, then that is more restrictive than the Medicare program and you must then follow your state practice act.