Documentation requirements
The medical record must clearly indicate the patient’s condition before, during, and after the therapy episode to support that the patient significantly benefitted from ongoing therapy services and that the progress was sustainable and of practical value when measured against the patient’s condition at the start of treatment.
Documentation should indicate clear objective evidence of improvement generally within the first week or 10 days of therapy (e.g., changes in weight, extremity circumference).
Codes in this policy
Code numbers and each code’s status as the policy records it. CPT code descriptions are left out of this page, as are the passages that cite CPT codes; the official document has them.