Essential Guide: Medicare Progress Notes Requirements for PT & OT Success

Progress notes provide the thread tying together patient documentation by chronicling the patient’s progress and the services the various team members provide. For Medicare, they serve multiple roles. They provide snapshots of the condition – each improvement and each setback. They also indicate the medical necessity of the various treatments. In doing so, they demonstrate the rationale of the program as well as its effectiveness.

Maintaining good documentation is more than writing clear notes. Failure to adhere to Medicare documentation standards can cause several problems, including denied reimbursements and potential audits. In this post, we will highlight the requirements for a Medicare progress note and give examples for your practice.

The Who, What, Why, and How of Medicare Progress Notes

Who Writes Progress Notes?

Physical therapists (PTs) and occupational therapists (OTs) are responsible for writing progress notes to ensure that every treatment aspect is accurately recorded. These notes detail an overview of the patient’s course, from daily notes to periodic reports. Physical therapy assistants (PTA) and occupational therapy assistants (OTA) can write portions of reports, but these are not considered complete progress notes.

What Elements Are Included in a Progress Note?

Progress notes need to be written at least once every ten treatment visits. The time spent writing these notes cannot typically be billed separately; as with all documentation, what’s covered varies by the patient’s payer. In some cases, excluding things like Medicare Part A, which are billed on a per diem basis rather than driven by CPT codes, it’s considered to be included in the payment for the treatment time charge.

These notes do not need to be separate from a daily treatment note. As long as it contains the necessary elements, Medicare will consider you in compliance with their documentation. So, what are the essential elements?

1. Date and Reporting Period: Indicate the beginning and ending dates of the reporting period, along with the date the report was written.
2. Identification: Ensure accountability by including the signature and professional identification of the individual writing the note.
3. Functional Status of the Patient: Include objective reports of any subjective statements by the patient.
4. Objective Measurements: Document any changes or objective measurements of the patient’s status relative to each treatment goal. These goals can include mobility, gait, or pain levels.
5. Assessment of Improvement: Evaluate progress (or lack thereof) toward each treatment plan goal.
6. Plans for Continuing Treatment: Clarify treatment plans and any revisions based on the current level of progress.
7. Changes to Goals or Discharge Plans: Note any changes to the overall plan to long or short-term goals.

No particular format is required for Medicare as long as all of the above elements are contained in the note and a note is written at least once every ten treatment visits. If co-treating with a PTA or OTA, the PT or OT must provide one full billable service on at least one service date during the period covered by the progress note. The PT/OT signature on the note indicates your compliance with this requirement.

Why Are Progress Notes Necessary?

From Medicare’s perspective, the primary purpose of Part B documentation is to show that the care being provided fully supports the medical necessity of the services offered. While daily treatment notes can justify billing, progress notes support the justification for continuing treatment.

Medical Necessity

First, a word on Medicare’s definition of medical necessity can help increase understanding. It has two parts. In the first part, it’s made clear that,“The patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.”

Additionally, it’s important to note that,“Improvement is evidenced by successive objective measurements whenever possible. If an individual’s expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.”

For rehabilitative therapy, Medicare needs the terms “improvement”, “expectation”, “reasonable”, and “predictable period of time” to be in your progress note. In short, your patient must be able to improve, and this should occur within a reasonable time frame.

The second part of this definition covers maintenance therapy. The criteria for medical necessity of this facet of treatment are:“In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent, or slow further deterioration of the patient’s functional status, and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.”

In this instance, your documentation must show medical necessity by demonstrating that your patient needs PT and/or OT care to prevent further deterioration of their functional status.

What Happens if the Progress Note Requirements Are Not Met?

The consequences of non-compliance with Medicare documentation can be significant. As mentioned, the progress notes’ content helps define medical necessity, which is used for billing and continuation of treatment. In addition to these, there are a few others.

1. Payment Determination: Contractors use progress notes to assess the necessity of the care given. Failure to document this accurately may result in delays or denials of payment.
2. Quality of Care: Documentation is essential, and not just for Medicare. Patient care can be compromised if records are incomplete or inaccurate.
3. Audits: Medicare contractors can trigger audits if they notice a pattern of non-compliance with documentation. These audits can result in increased scrutiny of records, further delaying payment.
4. Legal and Regulatory Risks: Allegations of fraud or abuse can stem from incomplete documentation.

How to Write a Progress Note

There are as many ways to write a progress note as there are people to write it, but many choose to use the SOAP format. You may already be familiar with the acronym, but for those new to the concept, we will outline how to use it for your progress notes. It is worth understanding the components, as many EMRs use them for their templates. SOAP stands for Subjective, Objective, Assessment, and Plan.

Subjective

This section is based on the patient’s opinions and experiences. It will include the chief complaint, updates on the patient’s function and symptoms, and treatment response.

Items to consider include:

• Chief complaint
• Pain scale
• Symptoms, including aggravating and alleviating factors
• Home exercise program and treatment response
• Patient’s perceived improvement
• Current activity level

Objective

This information will be gathered during the visit. Tests and measurements, interventions, and treatment provided during the visit will comprise the bulk of this section.

Depending on the condition(s) being treated, some of these may be included:

• Range of motion (ROM)
• Manual muscle testing (MMT)
• Vital signs and diagnostics
• Treatment conducted during visit (ex., exercise, manual therapy, education)
• Neurological testing
• Vestibular testing
• Posture and biomechanical testing

Assessment

This section combines the information in the first two sections, forming an opinion of the patient’s progress.

Components of the assessment may include:

• Differential diagnosis
• Professional assessment
• Response to care and treatment
• Existing impairments
• Functional limitations
• Safety issues
• Adjustments to current goals

Plan

This section outlines the treatment plan designed to meet treatment goals. It can also include any adjustments to the current plan, education, and frequency and duration.

Components may include:

• Plan for next visit
• Home exercise program progression
• Education
• Recommendations
• Adjustments to current plan

These four sections will give a comprehensive overview of the patient in general and the specific encounter. When written in the above format, another provider will easily understand the patient’s status and treatment goals.

Example of a Physical Therapy SOAP Note

Subjective

• Patient description: 45-year-old male presenting with chronic lower back pain.
• Symptoms: Moderate, persistent lower back pain, worsened by bending, twisting, and prolonged standing. Pain is somewhat managed with medication.
• Chief complaint: “I can’t do my usual activities or work without feeling a lot of pain in my back.”
• History of present illness: Patient reports the onset of symptoms approximately six months ago, with gradual worsening. No specific injury reported.
• Patient goals: To reduce back pain, improve mobility, and return to daily activities without discomfort.

Objective

• Physical examination: Moderate tenderness in the lumbar region, with no obvious deformities.
• Objective tests & measures: The Oswestry Disability Index (ODI) = 21, indicating moderate disability. Visual Analogue Scale (VAS) for pain = 6/10.
• Special tests: Straight Leg Raise (SLR) negative for radiculopathy.
• Observations: Patient displayed difficulty transitioning from sitting to standing and demonstrated a cautious gait pattern.
• Treatments/Interventions:
  • Manual therapy: Applied manual therapy techniques, including soft tissue mobilization to the lumbar paraspinal muscles and manual lumbar traction. The aim was to decrease muscle tension and improve segmental mobility of the lumbar spine.
    • Duration: 15 minutes.
  • Therapeutic exercise: Initiated a therapeutic exercise program focused on strengthening the core stabilizers and improving lumbar flexibility. Exercises included pelvic tilts (3 sets of 10 reps), cat-cow stretches for lumbar flexion and extension mobility (3 sets of 10 reps), and partial abdominal crunches to strengthen the abdominal musculature (3 sets of 10 reps).
    • Duration: 20 minutes.
  • Neuromuscular re-education:  Conducted neuromuscular re-education exercises, including single-leg balance to improve proprioception and postural stability and seated stability ball exercises to enhance core engagement and coordination during movements. Single-leg balance (each leg for 30 seconds, repeated 3 times), seated stability ball exercises focusing on maintaining an upright posture while performing gentle upper body movements (3 sets of 10 reps).
  • Duration: 15 minutes.

Assessment

• Diagnosis: M54.59 Other low back pain. The patient demonstrates moderate lumbar pain with associated functional limitations, particularly affecting movements requiring lumbar flexion and rotation.
• Progress: Not applicable, as this is the initial assessment.
• Possibility of functional impairment that will improve with skilled therapy: Yes, functional impairments in strength, ROM, and pain management can be addressed with skilled PT.
• Potential for rehab: Good, given the patient’s motivation and the absence of significant structural anomalies.

Plan

• Goals: Short-term goals include increasing lumbar ROM by 15% and improving functional strength for daily activities within 6 weeks. Long-term goals aim at returning to daily tasks without discomfort and enhancing mobility for stairs and walking within 4 months.
• Immediate interventions: To include manual therapy, lumbar stabilization exercises, and flexibility focused on the lumbar spine and surrounding musculature.
• Frequency: 2 sessions per week for the first 4 weeks, with reassessment planned for the fifth week. Adjustments to the treatment plan will be made based on the patient’s progress and tolerance to the interventions.

Here’s another example using a template.

Sample Occupational Therapy SOAP Note

This client has two goals. Briefly: Crossing the midline while participating in functional activities at school and using a functional grasp with a variety of writing utensils.

S: Upon entering the clinic, the client stated “I just woke up and am very tired.” The caregiver reported that the client uses his right hand about 70% of the time and switches to his left hand the rest of the time.

O: The client demonstrated a digital pronate grasp in 80% of opportunities and a violin grasp with all four fingers on the writing utensil in 20% of opportunities. Movement for coloring was generated from the client’s elbow and shoulder. Client uses his left hand with more frequency when the writing utensil is placed on his left side. The client fell out of his chair three times during the session and supported his neck with his hands while his elbows were propped on the table. He rested his head on the table in four occurrences. Physical (1) and verbal prompts (1 in 50% of trials) are needed for crossing the midline.

A: Hand dominance is still emerging and hand preference is often selected based on where the materials are (i.e. If the client has to cross the midline). The client demonstrates lack of proximal stability and postural control. This is contributing to difficulty isolating the smaller muscles of the hand for a functional grasp and therefore the ability to fully participate in coloring activities at school.

P: Provide midline crossing education and activity ideas to caregiver and teachers. Continue with OT 1x per week for 60 minutes to address midline crossing with fading physical and verbal cues as well as grasp. Monitor postural control and refer to PT if lack of stability persists. Provide the client with short utensils to promote emerging grasp.

Medicare Progress Notes: They’re for Everyone!

With a busy schedule, crafting progress notes may seem tedious at times, but they provide more than just the means for reimbursement. By following the above guidelines, you will present Medicare and other payers with the required information, but you will also provide subsequent providers with valuable information about the care you have provided. Rather than looking at the requirements as a necessary evil, use them to give the same quality of information as you provide in caring for your patients.