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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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Plan 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.

The plan is established when it is developed (e.g., written or dictated). The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded with the plan.

Establishing the Plan of Care

  • Who may create the POC?
  • When treatment can begin under a POC
  • Multiple Plans of Care

Contents of the Plan

  • Diagnosis
  • Long Term Goals (LTGs)
  • Type of Treatment
  • Multiple Disciplines
  • 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”?

Certification and Re-certification of the Plan


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