Documenting Skilled Therapy Services

Document clinical reasoning for modality/service

  • More than reps and task completion
  • Avoid using only status reports
  • Justify use of groups and avoid labeling groups with names such as ambulation
  • Reference comorbidities or cause of impairment and link to function
  • Reference how deficits and impairment relate
  • Keep daily notes

The Right Documentation

Example: “Pt. able to ambulate with wheeled walker, 150 ft, mod. assistance for maintaining balance and walker placement due to continued limitations in UE strength, fatigue, scissored gait, and tachycardia of 184 with task, resolved to 136 after 10 min. Spasticity inhabitation techniques taught to Pt. which assisted to reduce LE scissoring 5-8 steps at a time. Nursing informed of technique to use in room.”

CMS Three Hours Therapy Rule

“At least three hours, at least five days per week”

  • Do NOT interpret as 15 hours of service
  • Know how your intermediary interprets the rule
  • Most common variations
    • When three hours is counted: Begins day one of admission or begins first full day of admission
    • How days are determined: “Five days per week”
      • Week begins day of admission + six days
      • Week begins Sunday ends Saturday
  • Have a way to document minutes of therapy to support three hour “rule”
    CPT Codes (units of care) do not always cross reference to minutes


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