TY - CHAP M1 - Book, Section TI - Chapter 4. Content Standardization/Component Requirements A1 - Shamus, Eric A1 - Stern, Debra Feingold PY - 2011 T2 - Effective Documentation for Physical Therapy Professionals, 2e AB - 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. SN - PB - The McGraw-Hill Companies CY - New York, NY Y2 - 2024/03/29 UR - accessphysiotherapy.mhmedical.com/content.aspx?aid=55665293 ER -