Documenting Skill with Modalities

Todd Olson, OTR/L

April 23, 2019



How do you document "skill" appropriately when performing modalities?  


Many Medicare administrative contractors state that modalities are an adjunct to treatment and they do not expect to see more than two to three treatments before something active should be added to the treatment program. There's language in the RAI manual regarding modalities. In my organization, we've had to refer to this often when talking about documenting for modalities. This statement from the RAI manual states that only the time that is skilled may be recorded on the MDS. For example, a resident receiving TENS for pain management, the portion of treatment that is skilled, would be proper electrode placement, establishing proper pulse frequency and duration, and determining the appropriate stimulation mode, shall be recorded on the MDS. The use and rationale for all therapy modalities, whether skilled or unskilled, should always be documented as part of the resident's plan of care. My organization's Medicare administrative contractor is Noridian (these do vary depending on where you are located in the US). The portion of time that can be can be recorded and what they list as billable time with modalities are: proper electrode placement, establishing proper settings, removal of electrodes, and examining the skin before and after treatment. There is not a lot of "skilled" time for physical agent modalities. Documentation is key to supporting all skilled interventions no matter the procedure, including modalities. We need to note that the presence of a modality on a plan of care or in a daily note does not necessarily make it skilled, just because it's there. All regulatory language concerning skilled therapy delivery and documentation also applies to physical agent modalities.

Key components of documenting skill are:

  • modality must be clarified as part of the treatment plan including the location, frequency, and anticipated duration
  • the reason for the modality must be clearly described
  • the modality must be supported by the documentation in the rest of the chart
  • documentation should highlight the complexity and the necessity of using the modality,
  • relate the modality to an objective scale such as pain scale or edema,
  • document any adjustments and modifications.


todd olson

Todd Olson, OTR/L

Todd Olson, in his 22+ years of rehabilitation practice, has worked in acute care, inpatient rehabilitation, outpatient, and long-term care as a clinician, operator, researcher, legal expert witness, consultant, and educator.  In his current position as the Director of Clinical Education and Training for Brighton Rehabilitation, he provides continuing education, clinical, operational, and regulatory support to over 600 therapists throughout the western United States.  In this position, Todd has presented licensure approved clinical education programming on dementia management, falls and balance, pain management, activities of daily living, function-based intervention, documentation and coding, and regulatory/reimbursement compliance.  Todd also serves as Brighton’s electronic medical record (EMR) Clinical Applications Director. In this role, he provides EMR clinical, operational, financial, regulatory, and IT support to Brighton’s employees and customers. In addition, Todd is the Owner and President of Athena Therapy Consulting which provides quality assurance, auditing, and operational support to clinical and legal clients.  Outside of work, Todd enjoys spending time with his family and tempting fate on his snowboard and mountain bike in the Wasatch Mountains surrounding his home of Park City, Utah. 


Related Courses

Pain Management in Long Term Care
Presented by Todd Olson, OTR/L
Recorded Webinar


Todd Olson, OTR/L
Course: #3376Level: Introductory2 Hours
  'A course in pain in mandatory for my state licensure, but as a pediatric PT in schools, not as relevant'   Read Reviews
This course focuses on pain management programming in the long-term care setting from a therapist perspective as well as the interdisciplinary team approach. Participants will be able to define the classifications of pain, discuss how and why to implement pain management programming, understand the assessment process, identify skilled treatment options including a review of physical agents, and understand the components skilled documentation. This course is directly related to the practice physical therapy and is therefore appropriate for the PT and PTA.

Temporomandibular Joint-Anatomy/Physiology
Presented by Lori Steinley, PT, MS
Recorded Webinar


Lori Steinley, PT, MS
Course: #1071Level: Intermediate2 Hours
  'Detailed review with good graphics and descriptions of normal/abnormals mechanics of jaw'   Read Reviews
This course is designed to familiarize participants with the anatomy/physiology of the temporomandibular joint.

Temporomandibular Joint-Physical Therapy Assessment and Treatment.
Presented by Lori Steinley, PT, MS
Recorded Webinar


Lori Steinley, PT, MS
Course: #1072Level: Intermediate2 Hours
  'Thorough and practical, especially the detailed pictures accompanying explanations of anatomy, evaluation techniques and exercises'   Read Reviews
Please note: This course is also offered in a series of recordings titled "The Temporomandibular Joint", course 1416.

This course is designed to instruct participants in the physical therapy assessment and treatment of the temporomandibular joint-including discussion of modalities, manual techniques and home exercises.

Nerve Transfers
Presented by Marie Pace, M.H.S., OTR/L, CHT
Recorded Webinar


Marie Pace, M.H.S., OTR/L, CHT
Course: #2541Level: Intermediate1 Hour
  'Very informative and educational'   Read Reviews
Please note: This course is also offered in a series of recordings titled "Series: Hand Anatomy, Transplants and Nerve Transfers", course 1542 which is offered for AOTA/0.3 and NBCOT/3.75.

Recent innovations have made it possible to transfer part of a nerve from one location and move it to another, restoring sensory and motor function before primary nerve regeneration could restore function. This seminar will help the therapist responsible for rehabilitation to understand how recovery occurs and how to establish a treatment plan.

Introduction to Tuberculosis
Presented by Nannette Hanlin, RN
Recorded Webinar


Nannette Hanlin, RN
Course: #2130Level: Introductory1 Hour
  'Very concise and informative'   Read Reviews
According to the Centers for Disease Control (CDC), nearly 1/3 of the world’s population is infected with tuberculosis (TB) and it is considered one of the world’s deadliest diseases. We will define TB and discuss treatment, prevention, and strategies utilized when working with a patient with TB.