Medicare OT documentation requirements: what your record needs to support
Outpatient occupational therapy under Medicare Part B is documented to the same framework as physical therapy — evaluation, plan of care, treatment notes, progress reports — with OT-specific codes and the GO therapy modifier.
Four parts of an auditable OT record
Evaluation
Establishes the condition, functional deficits, and the need for skilled occupational therapy.
Plan of care
Functional goals, frequency, duration, and physician/NPP certification within required timeframes.
Treatment notes
What was done each visit, the skilled nature of it, and the time for timed services.
Progress reports
Objective progress toward goals that justifies continued skilled care.
OT specifics to get right
The GO modifier
Outpatient OT services are reported under an OT plan of care with the GO modifier.
Skilled vs. maintenance
The record must show why a qualified therapist’s skill was required, including for a maintenance program.
Functional necessity
Goals tied to activities of daily living and function, not generalized improvement.
Before signing an OT note
Necessity reads as skilled
The note defends why skilled OT — not an aide or self-management — was required.
Units reconcile to minutes
Timed OT code units match documented timed minutes.
Modifiers present
GO and any applicable KX/NCCI modifiers are in place and supported.
Frequently asked questions
What modifier identifies occupational therapy services to Medicare?
Medicare uses the GO modifier to indicate services delivered under an outpatient occupational therapy plan of care (GP for physical therapy, GN for speech-language pathology).
Does occupational therapy follow the 8-minute rule?
Yes. Timed outpatient OT codes follow the same Medicare 8-minute rule for 15-minute units as physical therapy. Confirm which codes are timed.
What makes OT documentation 'skilled'?
The record should show the services required the knowledge and judgment of a qualified occupational therapist — not that they were merely beneficial — with functional goals and progress that justify continued skilled care.
Verify against current CMS guidance
Educational summary only. Review the current Medicare manuals, applicable Medicare Administrative Contractor rules, and payer-specific policies. No article substitutes for clinical or billing advice.
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