Review ten documentation prompts for medical necessity.
Review the encounter note and relevant care plan using the ten prompts below. The interactive tool summarizes the boxes you select; it does not read a note or decide whether care meets a payer's requirements.
Read the full checklist below, or open the interactive version with your email.
The ten prompts
What to look for in the record.
These prompts organize a review. They are not a complete payer checklist or a rule that every item must be repeated in every note. Relevant information may appear elsewhere in the current record. Weights belong to this tool's model.
1. Diagnosis and applicable code
Check that the documented condition and code reflect the clinical assessment and service.
Model weight: 15
2. Current symptoms
Describe the current presentation so the record explains more than a diagnostic label.
Model weight: 12
3. Severity or frequency
Add relevant detail about intensity, frequency, or change to make the presentation understandable.
Model weight: 10
4. Effect on daily functioning
Connect the presentation to its effect on daily activities or relationships where relevant.
Model weight: 15
5. Baseline or prior functioning
Identify a relevant comparison point in the record for reviewing change over time.
Model weight: 8
6. Treatment goals
Check that the care plan identifies goals that can be reviewed against the clinical picture.
Model weight: 15
7. Interventions provided
Describe what was actually done and its relationship to the treatment plan.
Model weight: 12
8. Rationale for the service
Explain the clinical reason for care; a stock phrase alone cannot establish medical necessity.
Model weight: 10
9. Response or progress
Record the response to treatment, including limited progress or relevant changes.
Model weight: 8
10. Rationale for continued care
Explain the next step and why continued care is appropriate when it is planned.
Model weight: 10
How the result works
Selected weight divided by 115.
The tool adds the weights of selected items, divides by the total available weight, and rounds to a percentage. Selecting diagnosis, current symptoms, and severity gives 15 + 12 + 10 = 37: 37 ÷ 115 × 100 rounds to 32%. That is three selected prompts, not a 32% chance of approval.
Display bands start at 0%, 40%, 60%, and 80%. These custom weights and bands are not validated measures of documentation quality, clinical need, or payment likelihood. Even 100% means only that you selected every prompt.
Use the applicable policy and the full record.
This list does not cover all requirements. Check service dates, relevant time, provider identification, signatures, coverage, authorization, and other applicable rules separately. An unselected item can be a review question rather than a defect.
When you run the interactive checklist, your email, selected item IDs, and results are sent to Therapy Companion for storage. No note text is requested or uploaded. Read the privacy policy.
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Boundaries
What the checklist reads and what it cannot decide.
Review the actual record and current payer policy. A selection score cannot establish whether documentation supports the billed service.
- Reads
- The boxes selected by the visitor
- Does not read
- A note, chart, or uploaded document
- Returns
- A weighted summary of the items you selected
- Does not return
- A payer, coverage, billing, legal, or clinical determination
Source context / checked October 2, 2026
Examples of Medicare documentation guidance.
These sources explain relevant documentation topics. They do not endorse this tool, its ten-item selection, weights, or bands. Local Medicare policies apply within their stated scope and do not set requirements for every payer or plan.
CMS-hosted article A56937 distinguishes encounter documentation from information maintained across the record, including treatment plans and functional status. Review its documentation section and applicability.
LCD L34353 discusses interventions, progress summaries, care plans, and support for ongoing psychotherapy. Its coverage criteria depend on the service and setting.
Medicare Program Integrity Manual, Chapter 3 addresses the limits of templates in section 3.3.2.1.1. Section 3.3.2.5 describes identifiable, dated corrections and delayed entries. A higher checklist score does not justify changing a record to imply services or findings that did not occur.
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