Medicare Documentation Requirements

September 9, 2019
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Medicare Documentation Requirements

Initial Evaluation and POC

The following are Medicare’s current documentation requirements for initial evaluation and plans of care.

I.  Initial Evaluation (from Medicare Benefits Policy Manual Ch 15 Section 220.3(C))

A.  General goal is to document necessity for therapy through objective findings and subjective patient self-reporting.           

B.   Evaluation should list conditions/complexities and, where it is not obvious, describe impact of conditions/complexities on prognosis and POC.

C.   Evaluation must include:

1.  Diagnosis and description of specific problem(s) to be evaluated and/or treated.  In

most cases, both a medical diagnosis (obtained from physician) and an impairment

based treatment diagnosis are relevant.  Include all conditions and complexities that

may affect treatment.

2.  Results of one of the following measurement instruments are recommended, but not


  • Patient Inquiry by Focus on Therapeutic Outcomes, Inc. (FOTO)
  • OPTIMAL by Cedaron    

              If FOTO or OPTIMAL is not used, the therapist must document objective, measurable physical function including, for example:

  • Functional assessment individual item and summary scores (and comparisons to prior assessment scores) from commercially available therapy outcomes instruments; or
  • Functional assessment scores (and comparisons to prior assessment scores) from tests and measurements validated in the professional literature that are appropriate for the condition/function being measured; or
  • Other measurable progress towards identified goals for functioning in the home environment at the conclusion of this therapy episode of care.

  3.  Therapist clinical judgments or subjective impressions that describe current functional status of condition being evaluated.

  4.  Determination that treatment is not needed, or, if treatment is needed, prognosis for return to premorbid condition or maximum expected condition with expected timeframe and a POC.[1]

II.   POC Requirements (from Medicare Benefits Policy Manual Ch 15 Section 220.1.2)

A.  Establishing the POC 

1.  Medicare requires that the POC must be established before treatment is begun.

2.  The signature and professional identity of the person who established the POC and the date it was established must be recorded with the POC.

3.  Treatment may begin before the POC is committed to writing only if the treatment

is performed or supervised by the same clinician who establishes the POC.

B.  POC Contents

The POC must contain, at minimum, the following information:

  1. Diagnoses;
  • Long-term treatment goals;[2]
  • Type of treatment (PT or OT);[3]
  • Amount of treatment (number of times/day type of treatment will be provided-if not specified, once/day is assumed);
  • Duration (number of weeks or treatment sessions in this POC);
  • Frequency (number of times/week type of treatment provided-if not specified, once/week is assumed)

        Optional Content.  The above policy describes the minimum requirements for payment.  It is anticipated that clinicians may choose to make their plans more specific, in accordance with good practice.  For example, they may include these optional elements:  short-term goals, goals and duration for the current episode of care, specific treatment interventions, procedures, modalities or techniques and the amount of each.

C.  Changes to the POC

1.   Changes must be made in writing in the patient’s record by the therapist. 

2.   A physician may change a POC established by the therapist; however, a therapist may not significantly alter a POC certified by a physician without the physician’s written or documented verbal approval.  A change in LTGs would be a significant change.  Physician certification of the significantly modified POC must be obtained within 30 days of the initial therapy under the revised POC.  An insignificant alteration in the POC would be a change in frequency or duration due to the patient’s illness, or a modification of short-term goals to adjust for improvements made toward the same LTGs.

3.   Changes to procedures and modalities do not require a physician signature when they represent adjustments to the POC that result from normal progression in the patient’s disease or condition or adjustments to the POC due to lack of expected response.

III.  POC Certification (Medicare Benefits Policy Manual Chapter 15 Section 220.13)

A.  Initial POC Certification. Medicare requires the POC to be certified (signed and dated) by a physician, PA or NP. The initial certification is for the stated duration of the POC up to a maximum of 90 calendar days from the date of the initial evaluation. The initial certification is timely if it is dated within 30 calendar days of the initial evaluation. (See below for delayed certifications.)

B.  Recertification. Recertifications that document the need for continued (or modified) therapy should be signed whenever the need for a significant modification of the POC becomes evident, or at least every 90 days after the initial evaluation. Each recertification period can be for up to 90 days.

C.  Delayed Certification. Delayed certifications and recertifications are acceptable if the delayed certification includes a reason for the delay.  Certifications are acceptable without justification for 30 days after they are due. Delayed certifications should include any evidence the provider considers necessary to justify the delay.  For example, a certification may be delayed because the physician did not sign it or the original was lost. 

Therapy should not be stopped or denied when the certification is delayed.  The delayed certification of otherwise covered therapy should be accepted by CMS long as a physician is involved in the patient’s care.      

[1] Initial Eval Only. When an evaluation is the only service provided in an episode of care, the evaluation serves as the POC if it contains a diagnosis.  The goal, frequency and duration of treatment are implied in the diagnosis and one-time service.  The physician order is the certification that the evaluation is needed.  Therefore, when an evaluation is the only service, an order and evaluation are the only required documentation.  If the patient is evaluated without an order and does not require treatment, an order or certification of the evaluation is required for payment.  An order dated after the evaluation can be used as the certification.

[2] LTGs. Long-term treatment goals should be developed for the entire episode of care.  When the episode is anticipated to be long enough to require more than one certification, the long-term goals may be specific to the part of the episode that is being certified.  Goals should be measurable and pertain to identified functional impairments.

[3] Different Disciplines.  There must be different plans of care for each type of therapy discipline.  When more than one discipline is treating a patient, each must independently establish a diagnosis, goals, etc.