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Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs

Physical Therapy Plan of Care Requirements

Novitas Solutions in collaboration with Centers for Medicare & Medicaid Services (CMS) is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern is denial of outpatient rehabilitation therapy services due to missing physician/non-physician practitioner signature and dates on the certification of the plan of care.

Medicare defines rehabilitative services as those services that lead to "recovery or improvement in function and, when possible, restoration to a previous level of health and well-being."

Outpatient rehabilitation therapy services must relate directly to a written treatment plan (also known as the plan of care or plan of treatment). The plan of care must contain, at a minimum:

Diagnoses
Long-term treatment goals
Type, amount, duration, and frequency of therapy services

The plan of care is established by a physician, non-physician practitioner, physical therapist, an occupational therapist, or a speech-language pathologist. 

Note: Chiropractors and Dentists may not refer patient for therapy services nor certify therapy plans of care.

The signature and professional identity of the person who established the plan of care and the date it was established must be documented within the plan of care. The plan of care must be established before the therapy treatment can begin.

Establishing the plan of care is different than certifying the plan of care. Medicare states that certification of the plan of care requires a dated signature on the plan of care, or some other document, by the physician or non-physician practitioner who is the primary care provider for the patient. In the absence of a formal certification document, a physician's progress note indicating the physician's agreement with the plan of care is acceptable. The certification of the plan of care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment. Payment may be denied if the physician does not certify the plan of care; therefore, the therapist should forward the plan to the physician as soon as it is established.

Recertification of the plan of care, which also requires a physician or non-physician signature and date, should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification. Verbal orders for certification or recertification of the plan of care must be signed and dated by the physician/non-physician practitioner within 14 calendar days.

To avoid an error and the denial of services, when submitting documentation for review, be sure to:

Establish a complete initial plan of care to include:
Signature
Professional identification (i.e. PT, OT, etc.)
Date the plan was established
Ensure that the plan of care is certified (recertified when appropriate) with a physician/non-physician practitioner signature and date.
Clearly document when the plan of care has been modified, including how it was modified and why the previous goals could not be met.

References:

CMS Claims Processing Manual, Publication 100-04, Chapter 5, section 20

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Last modified:  05/31/2017