Posted November 11, 2022

See Medicare Documentation for more information.

What is a treatment note?

A record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. Documentation is required for every treatment day, and every therapy service.

What is required in each note?

The treatment note must include the following required information:

• Date of treatment;
• Identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;
• Record of the total time spent in services represented by timed codes under timed code treatment minutes;
• Record of the total treatment time in minutes, which is a sum of the timed and untimed services;
• Signature and credentials of each individual(s) that provided skilled interventions.

Is there additional information that can be added to the note?

The treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:

• Patient comments regarding pain, function, completion of self-management/home exercise program (HEP), etc;
• Significant improvement or adverse reaction to treatment;
• Significant, unusual or unexpected changes in clinical status;
• Parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;
• Description of the skilled components of the specific exercises, training, or activities;
• Instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;
• Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist);
• Communication with patient, family, caregiver;
• Equipment provided
• Any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.

When does the note need to be completed?

Medicare contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the progress report or treatment note refers.

Who must sign the treatment note?

Signature and professional identification of the qualified professional (therapist or assistant) who furnished or supervised the services and a list of each person who contributed to that treatment.

When the treatment is supervised without active participation by the supervisor, the supervisor is not required to cosign the treatment note written by a qualified professional.

State law may require that the supervising therapist co-sign the note with the assistant.

Reference

Centers for Medicare and Medicaid

Medicare Benefit Policy Manual

Chapter 15 – Covered Medical and Other Health Services