Occupational Therapy Medicare Documentation Handbook

Your note, not your care, is what gets paid. A Medicare reviewer never watched you work. They read your documentation and decide, from the page alone, whether a skilled therapist was required. When the words fall short, genuinely necessary care is denied. This handbook teaches occupational therapists how a reviewer actually reads, and how to write notes that prove skilled need. It covers skilled language, medical necessity, functional goals, the KX threshold, Section GG, homebound status, and audits and appeals, across outpatient, acute, inpatient rehab, skilled nursing, and home health. It closes with more than thirty-five copy-paste templates you adapt to each patient. Written for practicing OTRs and COTAs, clinic managers, and students, this is the practical guide to documentation that reimburses reliably and holds up under review.