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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medicare Plans of Care

Physical or occupational therapy services must relate directly and specifically to a written treatment plan. The plan, (also known as a plan of care or plan of treatment) must be established before treatment is begun.

Plan of Care FAQs

    • Who can establish a therapy plan of care (POC)?
    • Who must sign the POC?
    • Can treatment begin before a POC has been established?
    • What must be included in the POC?
    • How do I document the diagnosis in the POC?
    • How should long-term goals be documented?
    • Does the POC need to contain short-term goals?
    • What does type of treatment mean?
    • What if a patient is being treated by more than on kind of therapy?
    • What does amount of treatment refer to?
    • What does frequency refer to?
    • What does duration refer to?
    • Can a patient be treated under two POCs?


Establishing the Plan of Care

    • Who may create the POC?
    • When can treatment begin under a POC?
    • Can a patient be treated under multiple POCs?
    • What if the patient need treatment from different therapy disciplines? 

Contents of the Plan

    • Diagnosis
    • Long Term Goals (LTGs)
    • Type of Treatment
    • Amount of Treatment
    • Frequency of Treatment
    • Duration of Treatment

Changing the Plan

    • Who may make “significant” changes to the POC?
    • What is considered a “significant change”?
    • What changes are considered “insignificant”?


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Therapy Comply is a healthcare compliance firm that seeks to bring high quality web-based compliance guidance and one-on-one consulting services to small and medium size physical, occupational, and speech therapy practices.

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