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The Centers for Medicare and Medicaid Services (CMS), formerly HCFA, was the first to delineate documentation requirements for physical therapists (PTs) by a payer. Although there are some differences depending on setting and type of organization, there are basic requirements for all PT services: physician/appropriate referral (except for direct consumer access, although it may be required for third party reimbursement), initial examination/evaluation, plan of care (POC), certification of the POC (dependent on setting), ongoing documentation of care/continuum of care, reevaluation, and discharge summary or summation of care. There are also states, such as Florida, that include documentation requirements in the state practice act, although they are similar to those required for Medicare. In the past two decades, the American Physical Therapy Association (APTA) has developed guidelines for documentation that are similar to the Medicare guidelines (see Table 4-1). It is interesting to note that the Medicare program does not require providers to abide by the same requirements for Medicare and non-Medicare patients. However, in the states in which documentation requirements are included in the laws, and for those therapists that follow APTA guidelines, the requirements are similar and represent best practice standards.

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Table 4-1 Medicare (CMS) and APTA Guidelines for Documentation
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The use of standardized forms for documentation and billing purposes aids in maintaining consistency within an organization and between therapy personnel. Blank forms or pages lead to inconsistency and omission of information that may be crucial in supporting medical necessity for skilled physical therapy (PT) services. Although pre-designed or keyed forms (or formats in the electronic medical record) do not guarantee the quality of content, if keys or legends are provided in each category, the information is more likely to be included. The APTA's Guide to Documentation includes sample forms (see Appendix E).1 The forms in the guide are not detailed (with exception of the history) and therefore should be used only as a guide to develop forms that best suit a facility's or organization's needs. This is applicable to manual entry forms as well as electronically generated forms or formats.

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Because APTA documentation elements are generic and widely used, therapists should attempt to use them consistently, regardless of the third-party payer or payment system. ...

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