Quick Links

Tip: Press either “Ctrl + F” or “Command+F” on your keyboard and search for a keyword related to your intervention. You will then be able to copy and paste the caption.

Tips for Defensive Documentation

Use language from the OTPF-4

State rationale and skill as an analyst

State how it relates to your scope of practice

Be thorough and leave no room for interpretation 

Write so that nobody can  can question your value and competence

Write so nobody can question medical necessity and justification of services the first time

How to Build Treatment Documentation

with Language from the OT Domain

Therapeutic Activity Rationales

Billed as 97530

Self-Care and Community Management Rationales

Billed as 97535

Neuromuscular Re-Education Rationales

Billed as 97112

Psychosocial and Behavioral Rationales

Billed under main intervention code based on primary purpose