Quiz: Documentation for Part A & B – RMTP 2025

Multiple rule-sets guide therapy documentation in the SNF, including State Practice Acts, Medicare Part A, Medicare Part B and Non-Medicare payors. When Medicare rules and State Practice Act rules contradict each other,  which rule set is the priority to be followed?

Why is therapy documentation important?

The Medicare Part A and Medicare Part B documentation rules are the same in terms of frequency, content and which therapy professionals can complete each document.

The documentation rules for Medicare Part A can be found in Chapter _____ of the Medicare Manual; Medicare Part B rules can be found in Chapter _____.

Both Medicare Part A and Medicare Part B require daily therapy documentation to outline the skilled services provided.

What is the difference in purpose between a daily treatment note and a progress report?

Medicare Part B requires a clinician [ PT, OT or SLP] to write a Progress Report.

Medicare Part A does not address this in Chapter 8. However, the main reason that assistants [PTA, C/OTA] should not write Medicare Part A Progress Reports is:

Therapy documentation should clearly identify WHY the service is skilled and HOW the service is reasonable and necessary in frequency, duration and content.

Skilled therapy includes providing both Direct Care and Indirect Care.

Examples of Indirect Care include which of the following:

The Medicare Manual states that the following terminology found in therapy documentation may be cause for automatic denial of payment: