Therapy documentation for audit readiness

For OT, PT and SLP practices treating children, adults or both: an audit-ready Medicare record holds a signed plan of care with its certification, a progress report at least every 10 treatment days, a note for every treatment day with timed and total minutes, and a discharge note, each matching the claim. Medicaid and private plans add their own rules.⁠^1,2

What does Medicare require in an outpatient therapy record?

Five kinds of documents, each consistent with the claim: the evaluation and plan of care, the certification and any recertifications, progress reports including the discharge note, a treatment note for every treatment day, and, when care runs longer than is typical, an optional justification statement.⁠¹ The Medicare Benefit Policy Manual, chapter 15, section 220.3, says the record and the claim must consistently and accurately report the same covered services, and that documentation must be legible, relevant and sufficient to justify what was billed.⁠¹

Those are minimums. The manual says state or local law, a profession’s guidelines and a practice’s own policy may be stricter, and it tells reviewers to use APTA, AOTA and ASHA guidelines as guidelines rather than Medicare policy.⁠¹ It also tells contractors to read the whole record, so that one missing item does not cancel medical necessity the rest of the record shows.⁠¹

The rules below are Medicare’s. A child’s therapy billed to Medicaid answers to the state’s program, which for enrollees under 21 includes the EPSDT benefit, and therapy billed to a commercial plan answers to that plan’s policy.⁠¹⁵ This guide uses Medicare’s public, specific requirements as the working checklist and marks where other payers differ.

Which record elements fail review, and who requires each one?

The table pairs each Medicare record element with its source and the way reviewers report it missing; read each Medicaid or commercial manual for that payer’s version.

What must the initial therapy evaluation document for Medicare?

The problem and its effect on function, in enough detail that a reviewer can see why the planned care fits this patient. The manual asks for a diagnosis where state law allows the therapist to make one, with a description of the specific problem; for PT and OT, the body part evaluated; every condition and complexity that may affect treatment; the clinician’s own judgments; and either a finding that treatment is not needed or a prognosis with an expected time frame and a plan of care.⁠¹ It recommends, without requiring, results from one of four outcome instruments, ASHA’s National Outcomes Measurement System among them.⁠¹ The ICD-10-CM diagnosis coding guide covers the codes behind the diagnosis.

Only a clinician, meaning a physician, nonphysician practitioner or therapist and never an assistant, performs the evaluation; a PTA or OTA may contribute measurements within their scope, but the clinician takes part personally, and evaluation minutes count toward total treatment time, never the timed minutes.⁠^1,19 The level and coding of the evaluation are covered in the PT evaluation codes and OT evaluation codes guides.

What must a therapy plan of care contain for Medicare?

Diagnoses, long-term treatment goals, and the type, amount, frequency and duration of the therapy, set before treatment begins.⁠^3,16 The manual adds that the person who establishes the plan records a signature, professional identity and the date with it, that goals should be measurable and tied to functional impairments, and that each discipline keeps its own plan, so a physical therapist does not treat under an occupational therapist’s plan.⁠¹⁶

Procedures and modalities are the means, not the goals.⁠¹⁶ Write “climbs the school bus steps holding one rail, without help” or “orders a meal at a counter with one repetition requested,” not “neuromuscular reeducation” or “articulation therapy.” A change in long-term goals, such as treating a new condition, is a significant change that the physician or NPP certifies within 30 days of the first treatment under the revised plan; a change in frequency because the patient was ill, or new short-term goals toward the same long-term goal, is not.⁠¹⁶

When must a physician or NPP certify a therapy plan of care?

As soon as possible after the plan is established; the manual treats certification as timely when it is signed, or given as a verbal order, and dated within 30 days of the first treatment day, the evaluation included, and a verbal order needs a signature within 14 days.⁠^2,16 The certifying physician, nurse practitioner, clinical nurse specialist or physician assistant attests that the patient needs the therapy, is under the care of a physician or one of those practitioners, and is treated under a plan that meets the regulation, and recertification is required at least every 90 days.⁠²

Since January 1, 2025, a therapist’s initial plan can meet the signature requirement another way: the record holds the practitioner’s signed, dated written order or referral naming the type of therapy, plus evidence the plan was delivered to that practitioner within 30 days of the initial evaluation. CMS says the exception does not reach recertifications or plans in a comprehensive outpatient rehabilitation facility.⁠^2,17

A late certification can still be cured. The manual deems a delayed certification satisfied when the physician or NPP signs it with a reason for the delay, accepts one without a reason for 30 days after it was due, and calls a denial for a missing certification a technical denial that is overturned when an appropriate certification is produced.⁠¹⁶ For services in a therapist’s office, it says that denial leaves the patient liable, and recommends telling patients that certification is needed and what happens without it.⁠¹⁶

How often does Medicare require a therapy progress report?

At least once every 10 treatment days, written by the clinician, with the first period starting on the first day of the episode whether that day was an evaluation or a treatment.⁠¹ Days the patient is not seen do not count as treatment days, recertification dates do not move the progress report dates, and a report not written by the end of its period is due within 7 calendar days after it.⁠¹

A period is complete only when both the report and the clinician’s active participation are documented. Active participation means the clinician personally furnished at least one whole billable service on at least one treatment day, and the clinician’s signature on a treatment note or the progress report verifies it.⁠^1,19 Where a physical therapist assistant or occupational therapy assistant sees the patient between reports, the assistant may write elements of a report with objective measurements, but not a complete report, and may not judge why progress was or was not made.⁠¹

The clinician’s report assesses progress toward each goal, states the plan for continuing, and records any change to goals, a discharge, or an updated plan sent for certification.⁠¹ The manual counts standardized assessment instruments, outcome measurement tools and measurable functional outcomes as objective evidence; “increasing strength” is not an objective measurement, while a distance walked with a stated level of help is.⁠¹ When progress stalls or reverses, note the reason and the justification for continuing; a routine re-evaluation before every report is not required.⁠¹ A separate report is unnecessary when the treatment notes carry every required element at least once in the period.⁠¹ The discharge note is itself a clinician’s progress report, covering the time from the last report to discharge, and is required for each episode; the discharge guide covers what else it holds.⁠¹

For a child whose therapy Medicaid or a commercial plan pays for, the reporting interval is the one in that payer’s manual or authorization letter; a practice billing both can make the shorter interval its house rule.

What goes in a daily treatment note that passes review?

Four required elements: the date; each intervention furnished and billed, timed and untimed, named so it can be compared with the claim, including timed services that were not billed; total timed-code minutes and total treatment time; and the signature and professional identification of the person who furnished or supervised the care, with everyone who contributed.⁠¹ The billed units and the total timed minutes must agree, and contractors may not require the minutes of each intervention, since the billing shows them.⁠¹ The eight-minute rule guide works through the unit count, and the OT procedure codes and speech therapy CPT codes guides map the codes a note names.

The daily note does not have to argue medical necessity; the plan and progress reports carry that, and skilled descriptions are allowed each day but not required.⁠¹ It does have to record any treatment added or changed between reports, with the reason, and the manual says such changes help show the services were skilled.⁠¹

How do you show skilled care and not routine exercise in a note?

By writing what the therapist’s judgment changed. The manual says a service is not skilled just because a therapist or assistant furnished it, excludes general exercise for fitness and activities for diversion or motivation, and says skill shows in descriptions of skilled treatment, in changes made after the day’s assessment and in progressions toward a harder task.⁠^1,20 A diagnosis or prognosis alone does not decide the question; the test is whether a therapist’s skills are needed or the care could be carried out by nonskilled personnel.⁠²⁰

CMS discourages templates built from check boxes and predefined answers, saying review experience shows such templates often miss the clinical detail that proves coverage and coding requirements were met.⁠⁶ A note copied forward from the last visit has the same weakness: it cannot show a change the therapist made today, which is the evidence the manual names.

What do a passing and a failing therapy note look like?

A failing note records attendance; a passing note records what the clinician assessed, did, changed and measured, in words a reviewer can match to the claim and the plan.⁠¹ The two examples below are originals written for this guide, with invented patients and numbers.

Does Medicare pay for therapy that maintains function?

Yes, when a therapist’s skill is needed to design or carry out the program safely and effectively. CMS’s Jimmo settlement page says Medicare coverage of outpatient therapy turns on the patient’s need for skilled care, not on the potential to improve, and that a maintenance program is covered so long as skilled care is required.⁠^20,22 The settlement does not relax the other requirements: services still have to be reasonable and necessary, and the plan of care, certification and notes all still apply.⁠²²

The record has to show why the therapist is needed. Designing a maintenance program, teaching it and reassessing it are covered when they need a therapist’s skill; carrying out a program the patient or family can do safely is not, unless its procedures are complex or the patient’s complications require a therapist.⁠²⁰ A progress report for maintenance therapy shows that the therapist is necessary to maintain function or slow decline and that the patient, a family member, another caregiver or unskilled staff could not carry the services out safely.⁠¹

A child’s Medicaid therapy is judged differently: under EPSDT, the state determines medical necessity case by case.⁠¹⁵ The EPSDT guide covers what that record and request need, and the discharge guide covers when a plateau ends care and when it does not.

How do you correct or add to a therapy record after the visit?

Openly, with a dated entry by its author that leaves the original visible. CMS expects every service to be documented when it is rendered, and when an entry is amended, corrected or made late, the date and author of the change should be identifiable and the change clearly and permanently marked.⁠⁶ The manual’s definition of a date says the same: when a service is documented on a later day, both dates belong in the record.⁠¹⁹ Dictated documentation counts as completed on the day it was dictated, and a contractor may require notes and progress reports in the record within a week of the dates they cover.⁠¹

Never backdate, and never write a new entry to fit a records request. CMS’s own example is the plan of care: an attestation can identify who made an illegible signature, but it cannot backdate the plan, and reviewers refer records with potentially fraudulent entries to the UPIC.⁠⁶ A correction made after a request arrives is still a correction: label it, date it, and send it with the original.

What if a signature in a therapy record is missing or illegible?

Reviewers read the whole record: an illegible signature can be resolved with a signature log that lists each author’s typed name beside the initials or signature, and a missing one with an attestation signed and dated by the entry’s author.⁠⁶ The contractor asks whether the practice wants to send one within 20 calendar days; an attestation from anyone other than the author is not considered, and stamped signatures are generally not acceptable.⁠⁶ Keep a log for every clinician and assistant, with credentials, as CMS encourages.⁠⁶

Who reviews outpatient therapy claims and therapy records?

For Original Medicare, the Medicare Administrative Contractor, the Supplemental Medical Review Contractor, Recovery Audit Contractors, Unified Program Integrity Contractors and the CERT contractor can each request records; Medicaid programs, their managed care plans and private plans run reviews of their own.⁠^5,23

Count from the letter, not from a table. Noridian’s Jurisdiction F page, last updated July 18, 2025, lists 30 days for its RAC and 45 for its UPIC, the reverse of CMS’s current manual, and counts from the date on the letter; meet the date the request itself gives, and call the sender if the two disagree.⁠^6,31

Medicare Advantage plans, commercial plans and TRICARE review under their own policies and your agreement, so read the audit and recoupment terms before signing; the TRICARE guide covers that program.

How does Targeted Probe and Educate work for a therapy practice?

A MAC picks a provider and a service through data analysis, sends a letter, and reviews 20 to 40 of its claims with their records; if claims are denied, it offers one-on-one education and allows at least 45 days to improve before the next round, for up to three rounds.⁠^25,32 CMS says providers with high claim error rates or unusual billing are chosen, and compliant ones are not; a low-volume version reviews fewer than 20 claims a round.⁠²⁵ Each NPI and each service can be probed separately, and the appeal process is unchanged, with an overturned denial counted in later rounds.⁠³²

Problems that do not improve after three rounds go to CMS, which may order 100 percent prepayment review, extrapolation, a referral to a Recovery Auditor or other action.⁠²⁵ Among the common errors CMS names for TPE are a missing certifying physician’s signature and missing or incomplete certifications or recertifications.⁠²⁵

When can Medicare extrapolate an overpayment from a sample?

When the contractor determines that a sustained or high level of payment error exists, or that documented education has failed to correct the error; by law, the finding of a sustained or high error level cannot be appealed administratively or in court.⁠³³ The Program Integrity Manual lists a high error rate compared with similar providers and a history of noncompliance for the same billing issue among the signs, and requires a statistician or equivalent expert to approve the sampling method.⁠³³ The sample’s errors are then projected across the universe of claims the contractor defines for the review period, which is why fixing a documentation habit after the first round matters more than winning one claim.⁠³³

What do Medicare reviews find in therapy records?

Missing paperwork, more than disputed care. In CMS’s 2025 CERT supplemental data, covering claims submitted from July 1, 2023 to June 30, 2024, the top three root causes for the Part B service type CERT labels “minor procedures, other” were a missing PT, OT or speech therapy certification or recertification (62 sampled claims), a missing reason for a delayed certification (28) and a missing plan of care (20).⁠⁴ Further therapy rows were a missing progress report for a 10-treatment-day period (12), an inadequate plan of care (11) and missing therapy minutes (10), and 13 claims drew no response at all.⁠⁴

By provider type, the same report puts the improper payment rate for physical therapists in private practice at 19.9 percent, from 510 claims reviewed, with 88.3 percent of those improper payments in the insufficient documentation category; for occupational therapists in private practice the rate was 12.8 percent, from 45 claims, with 47.9 percent insufficient documentation and 32.6 percent no documentation at all.⁠⁴ CERT treats documentation as insufficient when a required element is missing or the record cannot show the service was provided, at the level billed, or medically necessary.⁠²⁶

An improper payment is not a fraud finding. CMS says all fraud produces improper payments but not every improper payment is fraud, and it describes the rate as a measure of compliance with federal rules.⁠²⁶ CMS’s fact sheet and a MAC’s published findings name the same gaps:

• CMS’s September 2025 fact sheet on therapy CERT errors (MLN905365): missing certifications, an unsigned or incomplete plan, uncertified plan changes, missing total minutes, an unsigned or undated evaluation, missing progress reports, and missing elements of medical necessity.⁠¹⁷
• Noridian, Jurisdiction F Part B: outpatient therapy services such as 97110 therapeutic exercise and 97140 manual therapy not supported because of insufficient documentation and incorrect coding, missing plans of care, certifications and progress reports, and documentation that supported a change in units (page last updated July 30, 2025).⁠¹⁸

The report’s provider-type tables have no separate row for speech-language pathologists in private practice, so no SLP rate appears here; the documentation rules above apply to SLP records all the same.⁠^1,4

How should a practice answer an additional documentation request?

Completely and on time: send everything that supports the billed dates, in an order a reviewer can follow, within 45 calendar days for a MAC, RAC, SMRC or CERT request and 30 for a UPIC.⁠^5,6 Contractors may accept late documentation for good cause, such as a natural disaster, but in post-payment review a request with no response is denied as not reasonable and necessary.⁠^5,6 CMS sends requests to the address on file in PECOS, so keep the medical review correspondence address current.⁠⁵

1. Log the request the day it arrives. Record the contractor, the claims and dates of service, the deadline and who owns the reply.
2. Pull the whole episode. CMS says documentation from before the review period may be needed, so include the evaluation and plan that cover the billed dates.⁠⁵
3. Check it against the decision table above. Find any missing certification, progress report or minutes before the reviewer does, and gather a delayed certification with its reason if one exists.⁠¹⁶
4. Add a signature log or attestation where needed. Only the author of an entry may attest to it.⁠⁶
5. Assemble in the order below, with the request letter on top. CMS calls putting the request letter first a best practice.⁠⁵
6. Send by a method the contractor accepts and keep proof. Mail, esMD, the MAC’s portal, fax or physical media are listed; keep a copy of every page sent and the receipt.⁠⁵

When a billing service handles these requests for the practice, the billing service guide covers who holds the records and the audit trail.

The KX line matters because Medicare keeps yearly thresholds, one for PT and SLP services combined and one for OT, above which claims must carry the KX modifier to confirm that the record documents medical necessity, and a targeted medical review process applies above a separate $3,000 amount.⁠⁶ The modifiers themselves are in the therapy modifiers guide, and the year’s KX amounts, from the patient’s side, in the Medicare therapy coverage guide.

How do you appeal a Medicare therapy overpayment?

Through five levels, starting with a written redetermination request to the MAC within 120 days of receiving the decision, which is presumed to arrive 5 days after the notice date.⁠^7,34,35 Each level has its own deadline, and the hearing and court levels require a minimum amount in controversy that changes each year.⁠⁷

Put the full evidence in early. CMS says documentation not submitted at the reconsideration level may be excluded at later levels unless there is good cause, and asks for all supporting documentation with the redetermination request.⁠^35,36 Minor errors and omissions are fixed through a reopening, not an appeal.⁠³⁵

Timing also protects cash. A MAC may begin recouping an overpayment no earlier than 41 days after the first demand, must stop when it receives a timely and valid redetermination request, and must stop again on a timely reconsideration request; at the hearing level and beyond, recoupment continues while the appeal is pending, and interest accrues.⁠⁸ The family’s side of a denial is in the therapy denial guide.

What if the practice finds its own overpayment first?

Report and return it within 60 days of identifying it, under 42 CFR 401.305; that deadline is suspended while a timely, good-faith investigation looks for related overpayments, until the investigation ends or 180 days after identification, whichever comes first.⁠³⁹ The rule reaches overpayments identified within 6 years of receipt, and a practice that calculates the amount by sampling must describe the sampling and extrapolation method in its report.⁠³⁹ Medicaid managed care plans must give their network providers a way to report an overpayment and return it within 60 calendar days, with the reason in writing.⁠¹⁴

How do Medicaid and private plans review pediatric therapy records?

Under their own rules, built on a federal floor: every Medicaid provider agrees to keep the records needed to show the extent of the services it furnishes and to give them, on request, to the Medicaid agency, the Secretary or the state’s Medicaid Fraud Control Unit.⁠¹² The same rules apply to an adult on Medicaid; the pediatric difference is EPSDT, under which the state decides a child’s medical necessity case by case.⁠^12,15

• State Medicaid RACs: a Medicaid RAC may not review claims more than 3 years old without the state’s approval, must notify providers of overpayment findings within 60 calendar days and works under state limits on record requests; the state must give providers appeal rights, and may leave managed care claims out.⁠¹³
• PERM: CMS measures improper payments in Medicaid and CHIP fee-for-service and managed care, reviewing each state once every three years; its provider page schedules the next records requests, for the 17 states of cycle 1, from April 1, 2027 to April 15, 2028, and none in report year 2027, which measures eligibility only.⁠^29,30
• Managed care plans: the state’s contract requires each plan to verify, by sampling or other methods, that services billed were received, and to run a compliance program with internal monitoring and auditing.⁠¹⁴
• Commercial plans: the provider agreement and the plan’s manual set the records, timelines and recoupment terms; ask for them in writing when you join, and keep the versions in force on each date of service.

The documents a child’s EPSDT record needs, from the order to the letter of medical necessity, are in the EPSDT guide; enrollment and revalidation are in the Medicaid enrollment guide.

How long should a therapy practice keep records for audits?

As long as the longest rule that applies. Medicare requires a provider or supplier that furnishes certified or referred services to keep documentation of the orders, certifications, referrals and payment requests for 7 years from the date of service and to give CMS or a contractor access on request.⁠⁹ The HIPAA Security Rule requires its own policies and compliance documentation to be kept for 6 years from creation or last effective date, which covers the practice’s security records, not the clinical chart.⁠¹⁰

For the medical record itself, HHS says the HIPAA Privacy Rule sets no retention period and that state laws generally govern it, while HIPAA’s safeguards apply for as long as the practice keeps the record, including at disposal.⁠¹¹ Before setting a pediatric schedule, check whether your state sets a different period for a minor’s records and when that period starts. Three more dates belong in the policy: the 6-year lookback for overpayments a practice identifies, the 3-year review window for Medicaid RACs, and whatever each payer agreement requires.⁠^13,39

The discharge guide covers releasing records to patients and families after care ends.

How would a Medicaid records request and a Medicare probe play out?

Both cases turn on documents the practice should have had before the letter arrived; the patients, practices and figures are hypothetical.⁠^12,25

The numbers are inputs to show the sequence, not rates to expect. In both cases the lasting fix was a template and a calendar, not the reply.

How do you audit your own therapy charts before a payer does?

Pull a small sample of each clinician’s charts on a set schedule, score them against the payer’s required elements, fix the process behind each miss, and report and return any overpayment you find.⁠^1,39 The manual tells clinicians to treat the discharge note as the last chance to justify the whole episode and to keep records organized so the required documentation is ready for a contractor; an internal audit is how a practice knows it is.⁠¹

Choose a sample size the practice can sustain every month rather than a large one done once. Track misses by element and by clinician, and recheck the same element next month.

Sources

1. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.3, Documentation Requirements for Therapy Services, Rev. 255, parts A to E). Checked October 26, 2026.
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   “To be payable, the medical record and the information on the claim form must consistently and accurately report covered therapy services, as documented in the medical record.”; “Documentation must be legible, relevant and sufficient to justify the services billed.”; “State or local laws and policies, or the policies or professional guidelines of the relevant profession, the practice, or the facility may be more stringent.”; “Contractors shall consider the entire record when reviewing claims for medical necessity so that the absence of an individual item of documentation does not negate the medical necessity of a service when the documentation as a whole indicates the service is necessary.”; “These types of documentation of therapy services are expected to be submitted in response to any requests for documentation, unless the contractor requests otherwise.”; “Evaluation and Plan of Care (may be one or two documents).”; “Certification (physician/NPP approval of the plan) and recertifications when records are requested after the certification/recertification is due.”; “Progress Reports (including Discharge Notes, if applicable) when records are requested after the reports are due.”; “Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes);”; “A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands their reasoning for services that are more extensive than is typical for the condition treated.”; “For Medicare purposes, dictated therapy documentation is considered completed on the day it was dictated.”; “contractors may require that treatment notes and progress reports be entered into the record within 1 week of the last date to which the progress report or treatment note refers.”; “a therapist’s skills may be documented, for example, by the clinician’s descriptions of their skilled treatment, the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.”; “The fact that services are typically billed is not necessarily evidence that the services are typically appropriate.”; “Documentation should establish through objective measurements that the patient is making progress toward goals.”; “It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.”; “The initial evaluation, or the plan of care including an evaluation, should document the necessity for a course of therapy through objective findings and subjective patient self-reporting.”; “A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated.”; “For PT and OT, be sure to include body part evaluated.”; “Evaluation minutes are untimed and are part of the total treatment minutes, but minutes of evaluation shall not be included in the minutes for timed codes reported in the treatment notes.”; “Include all conditions and complexities that may impact the treatment.”; “Results of one of the following four measurement instruments are recommended, but not required:”; “National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association”; “Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools; and”; “A clinician may include, as part of the evaluation or re-evaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or re-evaluation.”; “In many cases, both a medical diagnosis (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant.”; “A determination that treatment is not needed, or, if treatment is needed a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.”; “The progress report provides justification for the medical necessity of treatment.”; “The minimum progress report period shall be at least once every 10 treatment days.”; “The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, re-evaluation or treatment.”; “The progress report period requirements are complete when both the elements of the progress report and the clinician’s active participation in treatment have been documented.”; “Days on which a patient does not encounter qualified professional or qualified personnel for treatment, evaluation or re-evaluation do not count as treatment days.”; “It should be emphasized that the dates for recertification of plans of care do not affect the dates for required progress reports.”; “If the clinician has not written a progress report before the end of the progress reporting period, it shall be written within 7 calendar days after the end of the reporting period.”; “If each element required in a progress report is included in the treatment notes at least once during the progress report period, then a separate progress report is not required.”; “The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment.”; “The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge.”; “Clinicians should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed.”; “Reports written by assistants are not complete progress reports.”; “PTAs or OTAs may write elements of the progress report dated between clinician reports.”; “Note that assistants may not make clinical judgments about why progress was or was not made, but may report the progress objectively.”; ““increasing strength” is not an objective measurement, but “patient ambulates 15 feet with maximum assistance” is objective.”; “Assessment of improvement, extent of progress (or lack thereof) toward each goal;”; “Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report; and”; “Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.”; “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.”; “Objective evidence consists of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome.”; “Documentation is required for every treatment day, and every therapy service.”; “The treatment note is not required to document the medical necessity or appropriateness of the ongoing therapy services.”; “Date of treatment; and”; “Identification of each specific intervention/modality provided and billed, for both timed and untimed codes, in language that can be compared with the billing on the claim to verify correct coding.”; “Total timed code treatment minutes and total treatment time in minutes.”; “The billing and the total timed code treatment minutes must be consistent.”; “Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment”; “Patient self-report;”; “Adverse reaction to intervention;”; “Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist, etc.);”; “Significant, unusual or unexpected changes in clinical status;”; “Equipment provided; and/or”; “The amount of time for each specific intervention/modality provided to the patient may also be recorded voluntarily, but contractors shall not require it, as it is indicated in the billing.”; “Descriptions of skilled interventions should be included in the plan or the progress reports and are allowed, but not required daily.”; “If a treatment is added or changed under the direction of a clinician during the treatment days between the progress reports, the change must be recorded and justified on the medical record, either in the treatment note or the progress report, as determined by the policies of the provider/supplier.”; “New exercises added or changes made to the exercise program help justify that the services are skilled.”; “Utilize the guidelines of the American Physical Therapy Association, the American Occupational Therapy Association, or the American Speech-Language and Hearing Association as guidelines, and not as policy.”; “Only a clinician may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care.”; “Date of the beginning and end of the reporting period that this report refers to;”; “Date that the report was written (not required to be within the reporting period);”; “Objective reports of the patient’s subjective statements, if they are relevant.”; “The clinician must write a progress report during each progress report period regardless of whether the assistant writes other reports.”; “Verification of the clinician’s required participation in treatment during the progress report period shall be documented by the clinician’s signature on the treatment note and/or on the progress report.”; “The record should be reviewed and organized so that the required documentation is ready for presentation to the contractor if requested.”; “A re-evaluation should not be required before every progress report routinely, but may be appropriate when assessment suggests changes not anticipated in the original plan of care.”.
2. Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (eCFR, up to date as of October 22, 2026; paragraph (c), outpatient physical therapy, occupational therapy and speech-language pathology services). Checked October 26, 2026.
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   “The individual needs, or needed, physical therapy, occupational therapy, or speech-language pathology services.”; “The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant.”; “The initial certification must be obtained as soon as possible after the plan is established.”; “Recertification is required at least every 90 days.”; “When it is recertified, the plan or other documentation in the patient’s record must indicate the continuing need for physical therapy, occupational therapy or speech-language pathology services.”; “the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation, the certification does not need to be signed by a physician, NP, CNS, or PA who has knowledge of the case.”; “No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.”.
3. Code of Federal Regulations. 42 CFR 410.61, Plan of treatment requirements for outpatient rehabilitation services (eCFR, up to date as of October 22, 2026; paragraphs (b) to (d)). Checked October 26, 2026.
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   “The plan is established before treatment is begun by one of the following:”; “The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.”; “The changes are incorporated in the plan immediately.”.
4. Centers for Medicare & Medicaid Services. 2025 Medicare Fee-for-Service Supplemental Improper Payment Data (88-page report, released January 24, 2026 per CMS’s CERT Reports listing, covering claims submitted July 1, 2023 to June 30, 2024. Table 6, Top Root Causes for Minor procedures - other (Medicare fee schedule), lists by sample claim count: “Physical/Occupational/Speech Therapy - Certification/Recertification - Missing” 62; “Physical/Occupational/Speech Therapy - Reason for the delayed physician certification/recertification - Missing” 28; “Physical/Occupational/Speech Therapy - Plan of care - Missing” 20; “No response” 13; “Physical/Occupational/Speech Therapy - Required progress report, performed at least once every 10 treatment days - Missing” 12; “Physical/Occupational/Speech Therapy - Plan of care - Inadequate” 11; “Physical/Occupational/Speech Therapy - Therapy minutes - Missing” 10. Table J1, Improper Payment Rates by Provider Type and Type of Error: Part B, lists Physical Therapist in Private Practice at an improper payment rate of 19.9% on 510 claims reviewed, with 2.9% of its improper payments in No Doc, 88.3% in Insufficient Doc, 0.0% in Medical Necessity, 0.0% in Incorrect Coding and 8.8% in Other; and Occupational Therapist in Private Practice at 12.8% on 45 claims reviewed, with 32.6% No Doc, 47.9% Insufficient Doc, 0.0% Medical Necessity, 0.0% Incorrect Coding and 19.6% Other; neither Table I1 nor Table J1 has a row for speech-language pathologists in private practice, and both group provider types with fewer than 30 claims in one row, “All Provider Types With Less Than 30 Claims”). Checked October 26, 2026.
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   “Root causes associated with fewer than 5 sampled claims are excluded in Tables 1 through 13.”; “Please note that instances of fraud or other problems not discerned during the CERT review could still be present.”.
5. Centers for Medicare & Medicaid Services. Additional Documentation Request (page last modified March 4, 2026). Checked October 26, 2026.
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   “Medicare Fee-for-Service (FFS) medical reviews are conducted by Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractors (RACs), Unified Program Integrity Contractors (UPICs), and others.”; “An additional documentation request (ADR) is generated when documentation is necessary to support a Medicare claim.”; “The ADR is sent to a provider’s practice address on file with Medicare. To ensure you are receiving your ADR to the correct address, be sure to update your ’Medical Review Correspondence Address’ in the Provider Enrollment, Chain, and Ownership System (PECOS) system.”; “When preparing your documentation, it is best practice to attach a copy of the ADR letter as the first page to ensure the documentation is matched to the appropriate patient and claim.”; “Providers/Suppliers should submit the necessary documentation to support the services for the billing period being reviewed. This may include documentation that is prior to the review period.”; “Documentation may be received by your MAC either via US Mail, esMD, your MAC designated provider portal, Fax, or on compact disc (CD), digital video disc (DVD), or universal serial bus (USB).”; “As outlined in 42 CFR § 405.929 Post-payment review, a provider or supplier will be provided 45 calendar days to submit additional documentation in response to a contractor’s request.”; “As outlined in 42 CFR § 405.929 Post-payment review, A provider or supplier will be provided 30 calendar days to submit additional documentation in response to a UPIC’s request for additional documentation.”; “For MACs, SMRC, and RACs reviews, the contractor may accept documentation received after 45-calendar days for good cause.”; “if a contractor gives a provider or supplier notice and time to respond to an additional documentation request and the provider or supplier does not provide the additional documentation in a timely manner, the contractor has authority to deny the claim.”.
6. Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 3, Verifying Potential Errors and Taking Corrective Actions (Pub. 100-08, Rev. 13821, issued June 9, 2026; §3.2.3.2, Time Frames for Submission; §3.2.3.8, No Response or Insufficient Response to ADRs; §3.3.2.1.1, Progress Notes and Templates; §3.3.2.4, Signature Requirements; §3.3.2.5, Amendments, Corrections and Delayed Entries in Medical Documentation; §3.3.2.7, Review Guidelines for Therapy Services). Checked October 26, 2026.
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   “Per 42 CFR § 405.929, providers and suppliers have 45 calendar days to submit additional documentation in response to a MAC, RAC, SMRC or CERT request. Providers and suppliers have 30 calendar days to respond to a UPIC request.”; “During post-payment review, if no response is received within the expected timeframes (or extension), the MACs, RACs, UPICs and SMRC shall deny the claim as not reasonable and necessary.”; “CMS discourages the use of such templates.”; “Claim review experience shows that that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met.”; “Medicare contractors shall consider the totality of the medical record when reviewing for compliance with the above.”; “If the signature requirement is not met because the signature is illegible, the signature log process may be used to try and resolve the issue.”; “Providers will sometimes include a signature log in the documentation they submit that lists the typed or printed name of the author associated with initials or illegible signature.”; “Reviewers should encourage providers to list their credentials in the log.”; “Stamped signatures are not typically acceptable.”; “To be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.”; “the contractor shall ask if the billing entity would like to submit an attestation statement or signature log within 20-calendar days.”; “Reviewers shall NOT consider attestation statements from someone other than the author of the medical record entry in question”; “For example, if a statute, regulation, NCD or LCD states the physician must sign the plan of care before therapy begins, an attestation can be used to clarify the identity associated with an illegible signature. However, such attestation cannot be used to “backdate” the plan of care.”; “All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered.”; “The date and author of any amendment, correction or delayed entry should be identifiable, and the change/addenda should be clearly and permanently denoted.”; “If the MACs, CERT, SMRC or RACs identify medical documentation with potentially fraudulent entries, the reviewers shall refer the cases to the UPIC and may consider referring to the RO and State Agency.”; “the BBA of 2018 retains the targeted medical review (MR) process (first established through Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)), but at a lower threshold amount of $3,000.”; “The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were.”; “Section 50202 of the BBA of 2018 repeals application of the therapy caps but preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.”; “there is one amount for PT and SLP services combined and a separate amount for OT services.”; “For CY 2021 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services.”.
7. Code of Federal Regulations. 42 CFR part 405, subpart I, Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare (Part A and Part B) (eCFR, up to date as of October 22, 2026; §§405.942(a), 405.962(a), 405.1002(a), 405.1006(b) and (c), 405.1102(a) and 405.1130). Checked October 26, 2026.
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   “any request for redetermination must be filed within 120 calendar days from the date a party receives the notice of the initial determination.”; “the date of receipt of the initial determination will be presumed to be 5 calendar days after the date of the notice of initial determination, unless there is evidence to the contrary.”; “any request for a reconsideration must be filed within 180 calendar days from the date the party receives the notice of the redetermination.”; “The party files a written request for an ALJ hearing within 60 calendar days after receipt of the notice of the QIC’s reconsideration.”; “The party meets the amount in controversy requirements of § 405.1006.”; “For ALJ hearing requests, the required amount remaining in controversy must be $100 increased by the percentage increase in the medical care component of the consumer price index for all urban consumers (U.S. city average) as measured from July 2003 to the July preceding the current year involved.”; “For review requests, the required amount remaining in controversy must be $1,000 or more, adjusted as specified in paragraphs (b)(1) and (b)(2) of this section.”; “A party to a decision or dismissal issued by an ALJ or attorney adjudicator may request a Council review if the party files a written request for a Council review within 60 calendar days after receipt of the ALJ’s or attorney adjudicator’s decision or dismissal.”; “A party may file an action in a Federal district court within 60 calendar days after the date it receives notice of the Council’s decision.”.
8. Code of Federal Regulations. 42 CFR 405.379, Limitation on recoupment of provider and supplier overpayments (eCFR, up to date as of October 22, 2026; paragraph (d)). Checked October 26, 2026.
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   “Medicare contractors can begin recoupment no earlier than 41 days from the date of the initial overpayment demand but shall cease recoupment of the overpayment in question, upon receipt of a timely and valid request for a redetermination of an overpayment.”; “Upon receipt of a timely and valid request for a reconsideration of an overpayment, the Medicare contractor shall cease recoupment of the overpayment in question.”; “If the provider or supplier subsequently appeals the overpayment to the ALJ, the Medicare Appeals Council, or Federal court, recoupment remains in effect as provided in § 405.373(e).”; “Interest accrues and is payable in accordance with the provisions of § 405.378.”.
9. Code of Federal Regulations. 42 CFR 424.516, Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program (eCFR, up to date as of October 22, 2026; paragraph (f), Maintaining and providing access to documentation). Checked October 26, 2026.
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   “A provider or a supplier that furnishes covered ordered, certified, referred, or prescribed Part A or B services, items or drugs is required to—”; “Maintain documentation (as described in paragraph (f)(1)(ii) of this section) for 7 years from the date of service; and”; “Upon the request of CMS or a Medicare contractor, to provide access to that documentation”; “The documentation includes written and electronic documents (including the NPI of the physician or, when permitted, other eligible professional who ordered, certified, referred, or prescribed the Part A or B service, item, or drug) relating to written orders, certifications, referrals, prescriptions, and requests for payments for Part A or B services, items or drugs.”.
10. Code of Federal Regulations. 45 CFR 164.316, Policies and procedures and documentation requirements (eCFR, up to date as of October 22, 2026; HIPAA Security Rule; paragraph (b)). Checked October 26, 2026.
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    “Maintain the policies and procedures implemented to comply with this subpart in written (which may be electronic) form; and”; “If an action, activity or assessment is required by this subpart to be documented, maintain a written (which may be electronic) record of the action, activity, or assessment.”; “Retain the documentation required by paragraph (b)(1) of this section for 6 years from the date of its creation or the date when it last was in effect, whichever is later.”.
11. U.S. Department of Health and Human Services, Office for Civil Rights. Does the HIPAA Privacy Rule require covered entities to keep patients’ medical records for any period of time? (HIPAA FAQ 580, created February 18, 2009, content last reviewed July 26, 2013). Checked October 26, 2026.
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    “No, the HIPAA Privacy Rule does not include medical record retention requirements. Rather, State laws generally govern how long medical records are to be retained.”; “the HIPAA Privacy Rule does require that covered entities apply appropriate administrative, technical, and physical safeguards to protect the privacy of medical records and other protected health information (PHI) for whatever period such information is maintained by a covered entity, including through disposal.”.
12. Code of Federal Regulations. 42 CFR 431.107, Required provider agreement (eCFR, up to date as of October 22, 2026; paragraph (b)). Checked October 26, 2026.
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    “A State plan must provide for an agreement between the Medicaid agency and each provider or organization furnishing services under the plan in which the provider or organization agrees to:”; “Keep any records necessary to disclose the extent of services the provider furnishes to beneficiaries;”; “On request, furnish to the Medicaid agency, the Secretary, or the State Medicaid fraud control unit (if such a unit has been approved by the Secretary under § 455.300 of this chapter), any information maintained under paragraph (b)(1) of this section and any information regarding payments claimed by the provider for furnishing services under the plan;”.
13. Code of Federal Regulations. 42 CFR part 455, subpart F, Medicaid Recovery Audit Contractors Program (eCFR, up to date as of October 22, 2026; §§455.500 to 455.518). Checked October 26, 2026.
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    “This subpart implements section 1902(a)(42)(B) of the Act that establishes the Medicaid Recovery Audit Contractor (RAC) program.”; “Medicaid RAC program means a recovery audit contractor program administered by a State to identify overpayments and underpayments and recoup overpayments.”; “States may exclude Medicaid managed care claims from review by Medicaid RACs.”; “States must set limits on the number and frequency of medical records to be reviewed by the RACs, subject to requests for exception from RACs to States.”; “Notifying providers of overpayment findings within 60 calendar days.”; “The entity must not review claims that are older than 3 years from the date of the claim, unless it receives approval from the State.”; “The entity should not audit claims that have already been audited or that are currently being audited by another entity.”; “Fees paid to RACs must be made only from amounts recovered.”; “States must provide appeal rights under State law or administrative procedures to Medicaid providers that seek review of an adverse Medicaid RAC determination.”; “A State may seek to be excepted from some or all Medicaid RAC contracting requirements by submitting to CMS a written justification for the request for CMS review and approval through the State Plan amendment process.”.
14. Code of Federal Regulations. 42 CFR 438.608, Program integrity requirements under the contract (eCFR, up to date as of October 22, 2026; Medicaid managed care; paragraphs (a)(1), (a)(5) and (d)(2)). Checked October 26, 2026.
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    “A compliance program that includes, at a minimum, all of the following elements:”; “Establishment and implementation of procedures and a system with dedicated staff for routine internal monitoring and auditing of compliance risks, prompt response to compliance issues as they are raised, investigation of potential compliance problems as identified in the course of self-evaluation and audits, correction of such problems promptly and thoroughly (or coordination of suspected criminal acts with law enforcement agencies) to reduce the potential for recurrence, and ongoing compliance with the requirements under the contract.”; “Provision for a method to verify, by sampling or other methods, whether services that have been represented to have been delivered by network providers were received by enrollees and the application of such verification processes on a regular basis.”; “Each MCO, PIHP, or PAHP requires and has a mechanism for a network provider to report to the MCO, PIHP or PAHP when it has received an overpayment, to return the overpayment to the MCO, PIHP or PAHP within 60 calendar days after the date on which the overpayment was identified, and to notify the MCO, PIHP or PAHP in writing of the reason for the overpayment.”.
15. Medicaid.gov (Centers for Medicare & Medicaid Services). Early and Periodic Screening, Diagnostic, and Treatment (Medicaid benefit page). Checked October 26, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “It is the responsibility of states to determine medical necessity on a case-by-case basis.”.
16. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.1.1, Rev. 179; §220.1.2, Plans of Care, Rev. 255; §220.1.3, Certification and Recertification, Rev. 88). Checked October 26, 2026.
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    “Although there is no Medicare requirement for an order, when documented in the medical record, an order provides evidence that the patient both needs therapy services and is under the care of a physician.”; “The plan, (also known as a plan of care or plan of treatment) must be established before treatment is begun.”; “The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded with the plan.”; “Payment for services provided before a plan is established may be denied.”; “Diagnoses;”; “Long term treatment goals; and”; “Type, amount, duration and frequency of therapy services.”; “Goals should be measurable and pertain to identified functional impairments.”; “There shall be different plans of care for each type of therapy discipline.”; “Procedures (e.g., neuromuscular reeducation) and modalities (e.g., ultrasound) are not goals, but are the means by which long and short term goals are obtained.”; “Physician/NPP certification of the significantly modified plan of care shall be obtained within 30 days of the initial therapy treatment under the revised plan.”; “A change in long-term goals, (for example if a new condition was to be treated) would be a significant change.”; “An insignificant alteration in the plan would be a change in the frequency or duration due to the patient’s illness, or a modification of short-term goals to adjust for improvements made toward the same long-term goals.”; “The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of the certification requirements noted above in §220.1 for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less.”; “Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation).”; “If the order to certify is verbal, it must be followed within 14 days by a signature to be timely.”; “Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed.”; “Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay.”; “Certifications are acceptable without justification for 30 days after they are due.”; “Denial for payment that is based on absence of certification is a technical denial, which means a statutory requirement has not been met.”; “If an appropriate certification is later produced, the denial shall be overturned.”; “However, if the service is provided by a supplier (in the office of the physician/NPP, or therapist) a technical denial due to absence of a certification results in beneficiary liability.”; “For that reason, it is recommended that the patient be made aware of the need for certification and the consequences of its absence.”.
17. Centers for Medicare & Medicaid Services, Medicare Learning Network. Complying with Outpatient Rehabilitation Therapy Documentation Requirements (MLN Fact Sheet MLN905365, September 2025; its table of Common Outpatient Rehabilitation Therapy CERT Errors). Checked October 26, 2026.
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    “Starting January 1, 2025, we allow the physician or non-physician practitioner (NPP) written order or referral to substitute for the signature on the initial plan of care (POC) certification”; “This fact sheet describes common Comprehensive Error Rate Testing (CERT) Program errors related to medical record documentation.”; “Once the CERT Program identifies a claim in the sample, it requests (via fax, letter, or phone call) the associated medical records and other related documentation from the provider or supplier who submitted the claim.”; “Missing certification and recertifications”; “Confirm the physician or NPP certified the POC (and recertified it when appropriate) with their signature and date.”; “This applies only when the patient’s physician or NPP signs and dates the written order or referral, including information to identify the physician or NPP as well as the patient, and indicates the type of therapy needed”; “This policy doesn’t apply to recertifications or to POCs in a comprehensive outpatient rehabilitation facility (CORF).”; “Make sure you add your dated signature and professional identification (for example, PT, OT registered or licensed (R/L)) on the POC you established.”; “Create a complete POC that includes diagnoses, long-term goals, and service type, amount, frequency, and duration.”; “Certify a significantly modified POC (the physician or NPP signs and dates it).”; “Clearly document the total minutes for timed code treatment to support the number of units and codes billed for each treatment day, and document the total minutes of treatment time (including timed and untimed codes) in the patient’s medical record.”; “Document the initial evaluation with your signature, professional identification (for example, PT, OTR/L), and date of your initial evaluation”; “Progress reports justify medical necessity and require information like timing (at least once every 10 treatment days) and include your signature, professional identification, and date”; “Missing elements supporting medical necessity”; “We accept certifications without justification up to 30 calendar days after the due date.”.
18. Noridian Healthcare Solutions, Medicare Administrative Contractor for Jurisdiction F Part B (Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming). Common Errors (Comprehensive Error Rate Testing findings, Outpatient Therapy; last updated July 30, 2025). Checked October 26, 2026.
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    “Services provided in an Outpatient Therapy specialty, such as E/Ms, CPTs 97110, 97035, 97140 and HCPCS G0283 were not supported due to insufficient documentation and incorrect coding.”; “Therapy - Missing supportive documentation (i.e. plan of care, certification/re-certification, progress report, conservative treatments, etc.)”; “Therapy - Documentation supports UOS change”.
19. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220, part A, Definitions, Rev. 12425). Checked October 26, 2026.
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    “ACTIVE PARTICIPATION of the clinician in treatment means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.”; “The CLINICIAN is a term used in this manual and in Pub 100-04, chapter 5, section 10 or section 20, to refer to only a physician, nonphysician practitioner or a therapist (but not to an assistant, aide or any other personnel) providing a service within their scope of practice and consistent with state and local law.”; “CERTIFICATION is the physician’s/nonphysician practitioner’s (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.”; “A DATE may be in any form (written, stamped or electronic). The date may be added to the record in any manner and at any time, as long as the dates are accurate.”; “If services provided on one date are documented on another date, both dates should be documented.”; “INTERVAL of certified treatment (certification interval) consists of 90 calendar days or less, based on an individual’s needs.”; “The certification interval is not the same as a Progress Report period.”; “MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.”; “Routine weekly assessments of expected progression in accordance with the plan are not payable as re-evaluations.”.
20. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220.2, Reasonable and Necessary Outpatient Rehabilitation Therapy Services, Rev. 255, parts A, B, C and D). Checked October 26, 2026.
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    “A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist.”; “Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.”; “services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes.”; “Medicare coverage does not turn on the presence or absence of a beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care.”; “a beneficiary’s diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled.”; “The key issue is whether the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel.”; “Improvement is evidenced by successive objective measurements whenever possible”; “If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered.”; “If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered.”; “If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.”; “A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided.”; “Such skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the therapy procedures required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or (b) the particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedures.”; “skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.”; “Unlike coverage for rehabilitation therapy, coverage of therapy services to carry out a maintenance program does not depend on the presence or absence of the patient’s potential for improvement from the therapy.”.
21. American Speech-Language-Hearing Association. Speech-Language Pathology Treatment Codes Replacing 92507 (coding guidance; Key Dates). Checked October 26, 2026.
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    “CPT code 92507 remains in effect through December 31, 2026. The new codes take effect January 1, 2027.”; “Clinicians should not report the new codes before their effective date and should verify implementation requirements with each payer, as they may vary.”; “The new codes describe individual treatment by clinical service and use a time-based structure consisting of a base and add-on codes.”; “Other payers may decide if and when to implement the new codes into their fee schedules.”.
22. Centers for Medicare & Medicaid Services. Jimmo Settlement (CMS page on the January 2013 Jimmo v. Sebelius settlement agreement). Checked October 26, 2026.
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    “the Jimmo Settlement Agreement (January 2013), which clarified that the Medicare program covers skilled nursing care and skilled therapy services under Medicare’s skilled nursing facility, home health, and outpatient therapy benefits when a beneficiary needs skilled care in order to maintain function or to prevent or slow decline or deterioration (provided all other coverage criteria are met).”; “Skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are necessary for the performance of a safe and effective maintenance program.”; “The Jimmo Settlement Agreement may reflect a change in practice for those providers, adjudicators, and contractors who may have erroneously believed that the Medicare program covers nursing and therapy services under these benefits only when a beneficiary is expected to improve.”; “In essence, the Jimmo Settlement Agreement clarifies Medicare’s longstanding policy that coverage of skilled nursing and skilled therapy services in the Skilled Nursing Facility (SNF), Home Health (HH), and Outpatient Therapy (OPT) settings does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”; “The Jimmo Settlement Agreement does not alter or supersede any other applicable coverage requirements beyond those involving the need for skilled care, such as Medicare’s overall requirement that covered services must be reasonable and necessary to diagnose or treat the beneficiary’s condition, or existing statutory limitations on the amount or duration of Medicare benefits.”.
23. Centers for Medicare & Medicaid Services. Comprehensive Error Rate Testing (CERT) (page last modified August 25, 2026). Checked October 26, 2026.
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    “The CERT documentation requests identify that the requested documents are to be submitted within 45 calendar days of the request.”; “Each year, the CERT program reviews a statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and payment rules.”; “The fiscal year (FY) 2025 Medicare FFS estimated improper payment rate is 6.55 percent, representing $28.83 billion in improper payments.”; “The reporting period for this improper payment rate is July 1, 2023 through June 30, 2024.”.
24. Centers for Medicare & Medicaid Services. Medical Review and Education (CMS program page). Checked October 26, 2026.
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    “Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.”; “Medical review activities, such as the Targeted Probe and Educate program, are based on data analysis and other findings indicative of a potential vulnerability. This might include findings from the Comprehensive Error Rate Testing (CERT) Contractor, the Office of Inspector General (OIG), the Government Accountability Office (GAO), or the Recovery Audit Contractors (RACs).”.
25. Centers for Medicare & Medicaid Services. Targeted Probe and Educate (page last modified March 4, 2026; with the page’s process diagram and common-errors graphic, as their text alternatives read). Checked October 26, 2026.
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    “CMS’s Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.”; “providers and suppliers who have high claim error rates or unusual billing practices, and”; “items and services that have high national error rates and are a financial risk to Medicare.”; “Providers whose claims are compliant with Medicare policy won’t be chosen for TPE.”; “If chosen for the program, you will receive a letter from your Medicare Administrative Contractor (called a MAC). The MAC will review 20 to 40 of your claims and supporting medical records. If some claims are denied, you will be invited to a one-on-one education session. You will be given at least 45 days to make changes and improve, before another 20-40 claims are reviewed. This can happen up to 2 additional times. If compliant, you will not be reviewed again for at least 1 year on the selected topic.”; “MACs may conduct additional review if significant changes in provider billing are detected”; “However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps. These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action.”; “This program focuses on a review of less than 20 claims per round for up to three rounds.”; “The signature of the certifying physician was not included. Encounter notes did not support all elements of eligibility. Documentation does not meet medical necessity. Missing or incomplete initial certifications or recertification.”.
26. Centers for Medicare & Medicaid Services. Improper Payment Measurement in the Medicare Fee-for-Service (FFS) Program: Comprehensive Error Rate Testing (CERT) Program (slide deck, January 2025, linked from CMS’s CERT page). Checked October 26, 2026.
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    “While all payments stemming from fraud are considered improper payments, not all improper payments constitute fraud.”; “The improper payment rate is a measure of compliance with and adherence to federal rules and requirements and should not be viewed primarily as expenses that should not have occurred in the first place.”; “If no documentation is received within 75* days of the initial request, the claim is classified as a “no documentation” claim and counted as an error”; “Starting with report year 2026, errors will be assigned to claims if documentation is not received within 60 days.”; “Medical documentation submitted is inadequate to support payment”; “It could not be concluded that the billed services were actually provided, were provided at the level billed, and/or were medically necessary”; “A specific documentation element, that is required as a condition of payment, is missing”.
27. Centers for Medicare & Medicaid Services. Medicare Fee for Service Recovery Audit Program (page last modified September 28, 2026). Checked October 26, 2026.
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    “The Medicare Fee for Service (FFS) Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers”; “The RACs conduct both complex and automated post-payment reviews. Automated reviews occur at the system level while complex reviews require a qualified individual to review the medical record.”; “In order to obtain the medical record and any supporting documentation, the RAC shall issue an Additional Documentation Request (ADR).”; “Stay in the know on proposed and approved topics that RACs are able to review.”; “RACs in Regions 1-4 will perform post payment review to identify and correct Medicare claims specific to Part A and Part B.”.
28. Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 4, Program Integrity (Pub. 100-08, Rev. 13879, issued July 23, 2026; §4.1, Introduction; §4.2, The Medicare Program Integrity). Checked October 26, 2026.
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    “The primary principle of program integrity (PI) is to pay claims correctly.”; “The primary goal of the UPIC is to identify cases of suspected fraud, waste and abuse, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid.”; “Payment suspension and denial of payments and the recoupment of overpayments are examples of the actions that may be taken in cases of suspected fraud.”; “When the UPIC makes the determination that a matter is not potential fraud, waste, and/or abuse, the UPIC shall close the matter, or de-escalate the matter to the appropriate unit at the MAC, QIO, or other entity, when appropriate.”.
29. Centers for Medicare & Medicaid Services. Payment Error Rate Measurement (PERM) (page last modified March 12, 2026). Checked October 26, 2026.
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    “The PERM program measures improper payments in Medicaid and CHIP and produces improper payment rates for each program.”; “The improper payment rates are based on reviews of the Fee-For-Service (FFS), managed care, and eligibility components of Medicaid and CHIP in the year under review.”; “It is important to note that the improper payment rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory, or administrative requirements.”.
30. Centers for Medicare & Medicaid Services. Payment Error Rate Measurement (PERM): Providers (page last modified June 30, 2026). Checked October 26, 2026.
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    “This page was developed to help Medicaid and CHIP providers better understand the PERM process and what you may be required to do during a PERM review.”; “CMS uses a 17 or 18-State rotation cycle for PERM. Each State is reviewed once every three years.”; “PERM Cycle RY2028 Sampled Claim Review Period: July 1, 2026 to June 30, 2027”; “Timeframe for Medical Records Request Outreach: April 1, 2027 to April 15, 2028”; “Medical records request outreach to providers will not be conducted during RY 2027.”; “PERM will exclusively measure eligibility for the RY 2027 cycle.”; “Cycle 1 - Arkansas, Connecticut, Delaware, Idaho, Illinois, Kansas, Michigan, Minnesota, Missouri, New Mexico, North Dakota, Ohio, Oklahoma, Pennsylvania, Virginia, Wisconsin, Wyoming.”.
31. Noridian Healthcare Solutions, Medicare Administrative Contractor for Jurisdiction F Part B. Documentation Requests: How, Who and When to Send (JF Part B page, last updated July 18, 2025; its table of days to respond, counted from the date on the letter, lists 45 for Noridian prepayment and TPE review, 45 for Noridian post-payment review, 45 for CERT with “Non-responder contact at day 35” and “Denies after day 75”, 30 for the RAC (Cotiviti), 45 for the SMRC and 45 for the UPIC (Qlarant)). Checked October 26, 2026.
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    “A good rule of thumb is to send records which support the service and diagnosis(es) submitted on the claim as well as the medical necessity for the services.”; “Letters are sent to the Correspondence address on file in PECOS (Provider Enrollment, Chain and Ownership System) online enrollment site.”; “Post-payment reviews may result in either no change to the initial determination or a revised determination, indicating an underpayment or overpayment.”.
32. Centers for Medicare & Medicaid Services. Targeted Probe and Educate (TPE) Q & A’s (question-and-answer document linked from CMS’s TPE page). Checked October 26, 2026.
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    “TPE typically involves the review of 20-40 claims per provider/supplier, per item or service. This is considered a round, and the provider/supplier has a total of up to three rounds of review.”; “Providers/suppliers who are included in the TPE process will receive a notification letter from their MAC.”; “The appeals process is unchanged under the TPE process. If a claim denial is appealed and overturned, this would be taken into consideration in subsequent TPE rounds.”; “if a provider/supplier has multiple National Provider Identifiers (NPIs), each NPI could be subject to TPE review.”; “MACs can begin sending documentation requests for claims with dates of service no earlier than 45 days after the previous post-probe one-on-one education.”.
33. Centers for Medicare & Medicaid Services. Medicare Program Integrity Manual, Chapter 8, Administrative Actions and Sanctions and Statistical Sampling for Overpayment Estimation (Pub. 100-08, Rev. 13762, issued May 27, 2026; §8.4.1.2, The Purpose of Statistical Sampling; §8.4.1.4, Determining When Statistical Sampling May Be Used; §8.4.1.5, Consultation With a Statistical Expert). Checked October 26, 2026.
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    “A statistical sample is used to estimate the amount of overpayment(s) made on claims.”; “Defining the universe (target population) and the sampling unit, and constructing the sampling frame;”; “there must be a determination of sustained or high level of payment error, or documentation that educational intervention has failed to correct the payment error.”; “By law, the determination that a sustained or high level of payment error exists is not subject to administrative or judicial review.”; “The contractor shall use statistical sampling when it has been determined that a sustained or high level of payment error exists. The use of statistical sampling may be used after documented educational intervention has failed to correct the payment error.”; “high error rate determinations by the contractor or by other medical reviews compared to similar service providers;”; “provider/supplier history (i.e., prior history of non-compliance for the same or similar billing issues, or historical pattern of non-compliant billing practices);”; “The sampling methodology used in estimations of overpayments must be reviewed and approved by a statistician or by a person with equivalent expertise in probability sampling and estimation methods.”.
34. Centers for Medicare & Medicaid Services. Original Medicare (Fee-for-service) Appeals (page last modified August 25, 2026). Checked October 26, 2026.
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    “There are five levels in the Medicare Part A and Part B appeals process.”; “Redetermination by a Medicare Administrative Contractor (MAC)”; “Reconsideration by a Qualified Independent Contractor (QIC)”; “Decision by the Office of Medicare Hearings and Appeals (OMHA)”; “Review by the Medicare Appeals Council”; “Judicial Review in Federal District Court”; “A party may appoint any individual, including an attorney, to act as his or her representative during the processing of a claim(s) and /or any claim appeals.”.
35. Centers for Medicare & Medicaid Services. First Level of Appeal: Redetermination by a Medicare Contractor (page last modified March 10, 2026). Checked October 26, 2026.
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    “The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination to file a redetermination request.”; “A redetermination must be requested in writing.”; “A redetermination is a review of the claim by Medicare Administrative Contractor (MAC) personnel not involved in the initial claim determination.”; “The appellant should include with their redetermination request any and all documentation that supports their argument against the previous decision.”; “A minimum monetary threshold on the claim is not required to request a redetermination.”; “MACs do not process claim corrections involving minor errors and omissions through the appeals process.”; “Generally, the MAC will send its decision (either in a letter, an RA, and/or an MSN) to all parties within 60 days of receipt of the request for redetermination.”.
36. Centers for Medicare & Medicaid Services. Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (page last modified September 30, 2026). Checked October 26, 2026.
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    “The appellant (the individual filing the appeal) has 180 days from the date of receipt of the redetermination decision to file a reconsideration request.”; “A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).”; “A minimum monetary threshold is not required to request a reconsideration.”; “Any documentation not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless good cause is shown for not submitting the documentation previously.”.
37. Centers for Medicare & Medicaid Services. Third Level of Appeal: Decision by Office of Medicare Hearings and Appeals (OMHA) (page last modified January 6, 2026). Checked October 26, 2026.
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    “A request for an ALJ hearing must be filed with OMHA within 60 days of receipt of the reconsideration decision.”; “For calendar year 2026 the amount in controversy is $200.”; “ALJ hearings are held by telephone, unless the ALJ finds good cause for an appearance by other means such as video teleconference (VTC) or in person.”.
38. Centers for Medicare & Medicaid Services. Fifth Level of Appeal: Judicial Review in Federal District Court (page last modified August 31, 2026). “For calendar year 2026, the amount in controversy threshold is $1,960.”. Checked October 26, 2026.
39. Code of Federal Regulations. 42 CFR 401.305, Requirements for reporting and returning of overpayments (eCFR, up to date as of October 22, 2026; paragraphs (a), (b), (d) and (f), as amended December 9, 2024). Checked October 26, 2026.
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    “A person has identified an overpayment when the person knowingly receives or retains an overpayment.”; “The date which is 60 days after the date on which the overpayment was identified.”; “A person has identified an overpayment but has not yet completed a good-faith investigation to determine the existence of related overpayments that may arise from the same or similar cause or reason as the initially identified overpayment; and”; “The date that is 180 days after the date on which the initial identified overpayment was identified.”; “If the person calculates the overpayment amount using a statistical sampling methodology, the person must describe the statistically valid sampling and extrapolation methodology in the report.”; “An overpayment must be reported and returned in accordance with this section if a person identifies the overpayment, as defined in paragraph (a)(2) of this section, within 6 years of the date the overpayment was received.”.
40. DrSensory. Therapy Clinic Directory Pricing (the pricing page; its comparison of unclaimed and claimed listings). Checked October 26, 2026.
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    “Families never pay to search or to contact you.”; “Or $349.99 a year. Each additional location is $9.99 a month or $99.99 a year.”; “No contract. Cancel any time.”; “We do not verify clinical quality.”; “We do not sell your leads.”; the comparison marks “A description in your own words”, “Opening hours” and “Ages and conditions treated” as part of a claimed listing.
41. DrSensory. DrSensory for therapists (the For Therapists hub). Checked October 26, 2026.
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    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “Every clinic keeps a basic listing at no cost.”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “Inpatient rehabilitation facilities and chiropractic practices are not listed.”; “Claiming is free and has three steps: find your listing, confirm your email with a six-digit code, choose a password.”; “It does not mean DrSensory checked its clinical work.”.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. Its notes, patients and records requests are hypothetical examples, not DrSensory data or real patients; CPT codes belong to the American Medical Association and are described here in plain words.