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Does anyone audit therapy (OT, PT, SP) records? I would like to know what you look at. It seems that all coding audits are being done for E/M services. Thanks to anyone who can give me advise.
Fran
OT and PT records should include the time in and time out, the number of units per exercise and which exercise, any modalities rendered with the units, ROM measurements if measured, subjective findings as stated by the patient, and the plan of care. You should then be able to balance the total units billed with the time and time out that was documented.