Documenting therapeutic exercise should do more than show that a patient completed a list of exercises.
For CPT 97110, the note should help explain what was performed, why skilled therapy was needed, what impairment was being addressed, and how the intervention connects to the patient’s functional goals.
This guide provides practical CPT 97110 documentation examples for physical and occupational therapists, along with common mistakes that can make therapeutic exercise documentation harder to support.
What Should CPT 97110 Documentation Include?
CPT 97110 documentation should identify the therapeutic exercise performed, treatment parameters, skilled therapist involvement, the impairment being addressed, functional relevance, treatment time, patient response, and any progression or modification made during the session.
CPT 97110 is used for direct one-on-one therapeutic exercise intended to develop strength, endurance, range of motion, or flexibility.
For a complete explanation of the code, timed-unit rules, Medicare considerations, and billing requirements, see our CPT 97110 Billing, Documentation & Denial Prevention Guide.
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Key Takeaways
- The Qualified Business Income deduction is now permanent for eligible taxpayers.
- The 2026 Section 179 deduction limit is $2.56 million, subject to eligibility rules and phaseouts.
- Certain qualifying business property acquired after January 19, 2025 may qualify for 100% bonus depreciation.
- The 2026 business mileage rate is 5 cents per mile through June 30 and 76 cents per mile beginning July 1.
- Therapy practices should distinguish recurring business expenses, such as software subscriptions, from equipment purchases that may be subject to depreciation rules.
- Physical therapy and similar healthcare services can be treated as a Specified Service Trade or Business for QBI purposes, making income thresholds especially important.
What Should Be Included in a CPT 97110 Note?
A strong therapeutic exercise note usually answers several basic questions.
What exercise was performed?
Be specific enough that another clinician can understand what occurred.
Instead of:
Lower-extremity strengthening performed.
Consider:
Resisted knee extension performed for quadriceps strengthening.
What were the treatment parameters?
Depending on the intervention, relevant details may include:
- Sets and repetitions
- Resistance
- Duration
- Position
- Range of motion
- Assistance level
- Exercise progression
You do not need to overload every note with unnecessary detail. Include the information that helps explain the skilled service provided.
What did the therapist do?
This is one of the most important parts of the documentation.
Examples of skilled intervention may include:
- Verbal or tactile cueing
- Correcting movement patterns
- Progressing resistance
- Modifying the exercise
- Monitoring safety
- Adjusting positioning
- Assessing patient response
- Changing the intervention based on pain, fatigue, or performance
Simply documenting that a patient exercised may not clearly demonstrate why therapist expertise was required.
CPT 97110 Documentation Examples
Example 1: Shoulder Strengthening
Weak documentation:
Patient performed shoulder strengthening exercises.
Stronger documentation:
Patient completed resisted shoulder flexion, 3 sets of 10 with 2 lb resistance, to improve shoulder strength required for overhead dressing. Verbal cueing provided to reduce compensatory trunk movement. Resistance progressed from 1 lb based on improved movement control.
Why it is stronger:
The note identifies the exercise, resistance, clinical target, functional purpose, skilled cueing, and progression.
Example 2: Knee Strengthening
Weak documentation:
Patient completed leg exercises.
Stronger documentation:
Patient performed resisted knee extension, 3 sets of 10, to address quadriceps weakness affecting stair negotiation. Therapist provided cueing for controlled eccentric movement and adjusted resistance based on fatigue during the final set.
This shows why the exercise was selected and what the therapist contributed.
Example 3: Range of Motion
Weak documentation:
Shoulder ROM performed.
Stronger documentation:
Patient completed active-assisted shoulder flexion exercises to improve restricted range needed for upper-body dressing. Therapist adjusted hand placement and movement range to reduce pain and maintain proper scapular mechanics.
Example 4: Endurance
Weak documentation:
Endurance exercises completed.
Stronger documentation:
Patient completed repeated lower-extremity therapeutic exercise to improve muscular endurance required for prolonged household mobility. Exercise duration was increased from the previous session based on improved tolerance, with rest intervals adjusted due to fatigue.
How Do You Show Skilled Therapy in CPT 97110 Documentation?
One of the easiest ways to strengthen a therapeutic exercise note is to document what required the therapist’s clinical judgment.
For example, compare:
Patient completed 3 sets of 10 shoulder exercises.
with:
Patient completed 3 sets of 10 resisted shoulder flexion exercises. Therapist reduced resistance during the final set after observing increased upper-trapezius compensation and provided verbal and tactile cueing to restore movement quality.
The second example demonstrates that the therapist did more than supervise exercise.
It shows:
assessment → clinical decision → modification → patient response
That clinical reasoning is often what separates a skilled therapy note from a simple exercise log.
Connect Therapeutic Exercise to Functional Goals
Documentation becomes clearer when the therapist explains why improving a specific impairment matters to the patient.
Instead of:
Quadriceps strengthening for weakness.
Consider:
Quadriceps strengthening to improve controlled stair ascent and sit-to-stand transfers.
Instead of:
Shoulder ROM exercises.
Consider:
Shoulder range-of-motion exercises to improve the patient’s ability to reach overhead during dressing and household tasks.
The goal is not to force a functional phrase into every sentence.
The goal is to make the relationship between the impairment, intervention, and functional goal easy to understand.
Common CPT 97110 Documentation Mistakes
Copying the Same Exercise List Every Visit
Repeated exercise lists without documented progression or patient response can make it difficult to understand how the treatment is changing.
Document meaningful changes when they occur.
Documenting Equipment Instead of Clinical Purpose
Writing:
Resistance band exercises performed.
does not explain why the exercise was medically or functionally relevant.
The equipment does not determine the CPT code. The purpose of the intervention matters.
Missing the Skilled Therapist Component
Document what the therapist assessed, corrected, progressed, modified, or monitored.
Failing to Connect the Exercise to Function
The note should help explain why strength, endurance, range of motion, or flexibility needs to improve for this particular patient.
Using Vague Patient-Response Language
Statements such as:
Patient tolerated treatment well.
may be appropriate as part of the note, but they provide limited clinical information by themselves.
When relevant, document what changed:
Patient completed increased resistance without increased pain and required fewer verbal cues for movement control.
When CPT 97110 May Not Be the Best Code
Not every exercise-based intervention automatically belongs under CPT 97110.
A service may better support another therapeutic procedure depending on its primary purpose.
For example:
CPT 97110 generally focuses on developing strength, endurance, range of motion, or flexibility.
CPT 97530 focuses on dynamic therapeutic activities intended to improve functional performance.
CPT 97112 focuses on neuromuscular re-education, including areas such as balance, coordination, proprioception, and movement control.
The movement itself may look similar across different treatments. The clinical purpose and skilled intervention help determine which code best represents the service.
For a deeper comparison, see our CPT 97110 guide and 97110 vs. 97530 guide.
Looking up more cpt codes?
See 97110, 97530, and 50+ therapy procedure codes – with billing guidance and documentation tips in one place.
CPT 97110 Documentation Checklist
Before completing a therapeutic exercise note, ask:
- Did I identify the exercise performed?
- Did I include relevant treatment parameters?
- Did I explain what impairment was being addressed?
- Did I show why skilled therapist involvement was necessary?
- Did I connect the intervention to the patient’s functional needs?
- Did I document the patient’s response?
- Did I document meaningful progression or modification?
- Does the documented treatment time support the services reported?
The goal is not longer documentation.
The goal is documentation that clearly explains the treatment.
How HelloNote Supports Therapy Documentation
Keeping therapeutic exercise documentation consistent becomes harder when clinicians have to manage goals, treatment details, CPT codes, timed services, and billing information across separate systems.
HelloNote brings therapy documentation and practice-management workflows together so clinicians can keep the patient record, treatment information, CPT workflow, and billing settings connected.
For practices managing timed therapy services such as CPT 97110, having those pieces in one workflow can reduce the amount of information clinicians and billing teams need to reconstruct later.
Make Therapy Documentation Easier to Manage
Your clinicians should be able to document why the treatment was skilled, while the system helps keep the clinical and billing workflow organized.
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Frequently Asked Questions
What should CPT 97110 documentation include?
CPT 97110 documentation should identify the therapeutic exercise, relevant treatment parameters, skilled therapist intervention, the impairment being addressed, functional relevance, treatment time, patient response, and any clinically meaningful progression or modification.
Is listing exercises enough for CPT 97110?
Usually, an exercise list alone provides limited information about why skilled therapy was necessary. Documentation should also explain the therapist’s clinical involvement and the purpose of the intervention.
Do you need to document sets and repetitions for CPT 97110?
Sets and repetitions can provide useful treatment detail when relevant, but documentation should also explain the clinical purpose and skilled therapist involvement rather than relying only on exercise parameters.
What is the difference between CPT 97110 and 97530 documentations?
CPT 97110 documentation generally emphasizes therapeutic exercise aimed at strength, endurance, range of motion, or flexibility. CPT 97530 documentation should support dynamic therapeutic activities aimed at improving functional performance.
What are common CPT 97110 documentation mistakes?
Common mistakes include vague exercise descriptions, copying the same exercise list across visits, failing to document skilled therapist involvement, omitting the functional purpose of treatment, missing meaningful progression or patient response, and recording treatment time that does not clearly support the services reported.
How do you show skilled therapy in CPT 97110 documentation?
Common mistakes include vague exercise descriptions, copying the same exercise list across visits, failing to document skilled therapist involvement, omitting the functional purpose of treatment, missing meaningful progression or patient response, and recording treatment time that does not clearly support the services reported.
