What are the document required for outpatient therapy?

Documentation needed for Outpatient Therapy

•    Please be sure documentation submitted is legible.
•    Please submit records for all dates of service on the claim.
•    Please ensure the medical records submitted provide proof the service(s) was ordered and rendered. Also, ensure the medical records provide justification supporting medical necessity for the service by submission of the following documentation:
o    Current level of function.
o    Prior level of function.
o    Initial therapy evaluation.
o    Any previous therapy administered.
o    Diagnosis onset date.
o    Grid reflecting services(s)/HCPCS.
o    Medical diagnosis.
o    Physician certification and recertification.
o    Physician’s orders.
o    Progress notes detailing services provided for each date of service billed.
o   
o    Treatment diagnosis.
o    Treatment plan with long- and short-term goals.
o    Description of instrument used for selective or sharp debridement for wound care services (if applicable).
o    Signatures/credentials of professionals providing services.
o    Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the Additional Documentation Request (ADR) letter.