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Medicare Plan of Care FAQs

Posted on October 26, 2022

See our Medicare Plan of Care Section for more information.

Who can establish a therapy plan of care (POC)?

Outpatient therapy services shall be furnished under a plan established by:

    • A physician/NPP (consultation with the treating physical therapist, occupational therapist, or speech-language pathologist is recommended. Only a physician may establish a plan of care in a CORF;
    • The physical therapist who will provide the physical therapy services;
    • The occupational therapist who will provide the occupational therapy services; or
    • The speech-language pathologist who will provide the speech-language pathology services.

Who must sign the POC?

The person who established the plan must sign and date the plan.  The physician/NPP must also certify the plan by signing and dating it.

See Certification and Recertification for more information.

Can treatment begin before a POC has been established?

Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who establishes the plan. Payment for services provided before a plan is established may be denied.

What must be included in the POC?

The plan of care shall contain, at minimum:

    • Diagnoses;
    • Long term treatment goals; and
    • Type, amount, duration and frequency of therapy services.

How do I document the diagnosis in the POC?

The diagnosis should be specific and as relevant to the problem being treated as possible. In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.

The ICD-10 code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason.

When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position.

Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.

How should long-term goals be documented?

Long term treatment goals should be developed for the entire episode of care in the current setting. When the episode is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified. Goals should be measurable and pertain to identified functional impairments.

Long-term goals should:

    • Pertain to the functional impairment findings documented in the evaluation;
    • Reflect the final level the patient is expected to achieve as a result of therapy in the current setting;
    • Be realistic, and should have a positive effect on the quality of the patient’s everyday functions;
    • Be function-based and written in objective, measurable terms with a predicted date for achieving the goals.

Does the POC need to contain short-term goals?

Short-term goals are not required.  Therapists typically also establish short term goals, such as goals for a week or month of therapy, to help track progress toward the goal for the episode of care. If the expected episode of care is short, for example therapy is expected to be completed in 4 to 6 treatment days, the long term and short-term goals may be the same.

What does type of treatment mean?

The type of treatment may be PT, OT, or SLP, or, where appropriate, the type may be a description of a specific treatment or intervention. (For example, where there is a single evaluation service, but the type is not specified, the type is assumed to be consistent with the therapy discipline (PT, OT, SLP) ordered, or of the therapist who provided the evaluation.)

When a physician/NPP establishes a plan, the plan must specify the type (PT, OT, SLP) of therapy planned.

What if a patient is being treated by more than on kind of therapy?

When more than one discipline is treating a patient, each must establish a diagnosis, goals, etc. independently. However, the form of the plan and the number of plans incorporated into one document are not limited as long as the required information is present and related to each discipline separately.

For example, a physical therapist may not provide services under an occupational therapist plan of care. However, both may be treating the patient for the same condition at different times in the same day for goals consistent with their own scope of practice.

What does amount of treatment refer to?

The amount of treatment refers to the number of times in a day the type of treatment will be provided. Where amount is not specified, one treatment session a day is assumed.

What does frequency refer to?

The frequency refers to the number of times in a week the type of treatment is provided. Where frequency is not specified, one treatment is assumed. If a scheduled holiday occurs on a treatment day that is part of the plan, it is appropriate to omit that treatment day unless the clinician who is responsible for writing progress reports determines that a brief, temporary pause in the delivery of therapy services would adversely affect the patient’s condition.

What does duration refer to?

The duration is the number of weeks, or the number of treatment sessions. If the episode of care is anticipated to extend beyond the 90 calendar day limit for certification of a plan, it is desirable, although not required, that the clinician also estimate the duration of the entire episode of care in this setting.

Can the amount, frequency, or duration be changed during the episode of care?

Yes. The plan of care can be altered by the therapist during treatment.  If the therapist changes the long-term goals, then the POC must be recertified by the physician/NPP.

References

Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services §220.1.2

Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067

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