Please note that this article contains information that is only relevant to American clinics.

 

Many PT and OT assistants often wonder if they’re able to sign and complete clinical notes on their own. In other words, they’re wondering if they need a supervising PT or OT to co-sign the note for them. In this article, we’ll be taking a closer look at whether PT and OT assistants need the supervising therapist to co-sign notes for them. More specifically, we’ll be looking at how individual insurance carriers and state practice acts impact this rule.

 

Many ask whether the Medicare program requires that clinical notes be cosigned by the supervising therapist. A recent article from Gawenda Seminars and Consulting explained that Medicare does not require notes to be signed by the supervising therapists.

 

Another question on the lips PT and OT assistants is whether private insurance carriers require notes written by assistants to be co-signed by their supervising therapist. Unfortunately, the answer to this question isn’t as cut and dried as it is with Medicare. As it turns out, it varies from insurance carrier to insurance carrier. In most cases, they won’t require a co-signature, but it’s your responsibility to speak with your insurance carrier and see if they’ll need that additional signature.

 

Lastly, PT and OT assistants often inquire about whether their state practice act requires that the supervising therapist co-sign completed clinical documentation. Like insurance carriers, most do not have this requirement but you’ll still need to check for good measure. And even if the insurance carrier didn’t require a supervising therapist to co-sign the note, a state practice act stating the requirement would override the insurance carrier’s mandate.

 

To recap, Medicare does not require clinical notes to be co-signed, most insurance carriers don’t either but you still need to check, and the same goes for state practice acts.

 

We hope you found this article helpful. For more great content like this, check out the Gawenda Seminars and Consulting website and learn more about the benefits of becoming a Gold Member.

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