AOTA-DOCUMENTATION-BILLING — AOTA Advisory: Ethical Documentation and Billing Practices
What does AOTA-DOCUMENTATION-BILLING say?
Documentation and billing ethics are among the most frequently cited ethical challenges for OT practitioners. Key guidance from the 2025 Code (Standards of Conduct — Documentation and Reimbursement): (1) Documentation must accurately reflect services provided, client status, and clinical reasoning. (2) Billing codes must correspond to actual services delivered — upcoding, unbundling, and billing for services not rendered constitute fraud. (3) Productivity demands from employers must not compromise documentation integrity. (4) Co-signatures on student or OTA documentation indicate the supervising therapist has reviewed and approved the content. (5) Copying and pasting previous documentation ("cloned notes") without updating for the current session is fraudulent. (6) Progress notes must reflect actual client performance, not aspirational goals. (7) Discharge documentation must include measurable outcomes and appropriate recommendations. (8) Electronic health record entries must be timely and accurate. (9) Practitioners who observe documentation fraud have an ethical obligation to report it. (10) Federal and state laws (False Claims Act, Anti-Kickback Statute) impose severe penalties for billing fraud. Related Principles: Veracity (truthfulness), Fidelity (professional obligations), Justice (equitable resource allocation).
Official source: read the full text in the AOTA Occupational Therapy Code of Ethics (2025) (official document).