Documentation submitted includes the initial evaluation and plan of care with documented goals of therapeutic intervention that include the following:
Long term treatment goals: Should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care.
Type: May be physical therapy, occupational therapy, or speech language pathology, or when appropriate, the type may be a description of a specific treatment or intervention. When a physician or NPP (non-physician practitioner) establishes a plan, the plan must specify the type of therapy planned.
Amount: Refers to the number of times in a day the type of treatment will be provided.
Duration: Number of weeks or the number of treatment sessions for the plan of care.
Frequency of therapy services: Refers to the number of times in a week the type of treatment is provided.
Modifications: If any modifications are made to the plan of care, it should include how it has been modified and why the previous goals were note met or could not be met.