Skip to Main Content

We have a new app!

Take the Access library with you wherever you go—easy access to books, videos, images, podcasts, personalized features, and more.

Download the Access App here: iOS and Android



Following completion of this chapter, the reader will be able to:

  • Discuss the basic requirements for Medicare documentation.

  • Identify ten content elements required in the initial examination and evaluation.

  • Analyze the relationship between the patient/client’s prior level of function and physical therapy.

  • Describe the basic content requirements for a plan of care.

  • Discuss the recommended frequency of documentation.

  • List examples of terms that should be avoided in documentation.

  • Compare and contrast certification and recertification in the Medicare context.

  • Discuss under what circumstances is gait training skilled versus unskilled.


There are basic requirements for all physical therapy services: initial examination/evaluation, plan of care (POC), ongoing documentation of care/continuum of care, re-evaluation, and discharge summary or summation of care. The Centers for Medicare & Medicaid Services (CMS) was the first to delineate documentation requirements for physical therapists (PTs) by a payer source. Although there are some differences depending on the setting and the type of organization, the basic requirements are always included. Documentation is also guided by insurance mandates and language in a state’s practice act. Florida, for instance, has documentation requirements that each therapist has to follow, although they are similar to those required by CMS for Medicare. The American Physical Therapy Association (APTA) has developed guidelines for documentation that are similar to the Medicare guidelines (see Table 5-1). The APTA guidelines represent best practice standards.

Table 5-1Medicare (CMS) and APTA Guidelines For Documentation

The use of standardized formats or templates for documentation and billing purposes aids in maintaining consistency within an organization or facility, as well as 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 services. Although predesigned 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 the exception of the history) and therefore should ...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.