Medical documentation for third-party payers

Medical documentation of patient care by physical therapy has become a requirement for reimbursement of health services paid by federal and state programs or by other third-party payers. The medical record of physical therapy must satisfy several specific requirements of third-party payers before health services can be reimbursed. The fiscal intermediaries require a precise, written statement of the patient's physical problems, treatment goals and plan, and objective information on the patient's response to treatment. The criteria reflected for third-party payment must be satisfied and evident in succinct and accurate documentation in the medical record. Medical documentation must show evidence of a prescription, medical reason for treatment, a viable discharge plan, outcome of treatment, coordination of medical services, patient instruction, and discontinuance or adaptation of services when necessary. The requirements for third-party payment based on medical documentation are discussed.