“Simple” and “Medicare” are rarely used in the same sentence, but that doesn’t have to be the case—especially when it comes to developing physical therapy, occupational therapy, and speech-language pathology plans of care (POCs) and adhering to certification requirements. While these treatment outlines might seem daunting at first, there are totally easy-to-follow guidelines to ensure yours are always comprehensive and compliant. To that end, here are eight simple rules for creating a Medicare POC—so you can provide treatment to patients who need you and get paid:

Physical Therapy Billing Open Forum - Regular BannerPhysical Therapy Billing Open Forum - Small Banner

1. Provide all the details.

As we explain here, plans of care must—at minimum—include:

  • “Medical diagnosis
  • “Long-term functional goals
  • “Type of services or interventions
  • “Quantity of services or interventions (number of times per day the therapist provides treatment; if the therapist does not specify a quantity, Medicare will assume one treatment session per day)
  • “Frequency of treatment (number of times per week; do not use ranges); and
  • “Duration of treatment (length of treatment; do not include ranges).”

It’s also important to note that if therapists in different disciplines (e.g., PT, OT, and SLP) are providing treatment to the same patient, then there must be a plan of care established for each speciality, “and each therapist must independently establish what impairment or dysfunction he or she is treating as well as the associated goals.”

2. Ensure that a licensed provider creates the POC.

While Medicare does allow PT, OT, and SLP assistants to provide services to Medicare beneficiaries under certain conditions, it requires that all plans of care be established by fully licensed providers. That means only PTs, OTs, and SLPs should develop patient treatment plans.

3. Use functional goals.

In order to best connect the plan of care with the patient’s story, providers should craft functional goals using the SMART formula. That means your goals should be:

  • Specific;
  • Measurable;
  • Achievable;
  • Relevant; and
  • Time-oriented.

In other words, instead of setting a goal to, say, improve shoulder range of motion by one degree, consider an approach that is more meaningful to the patient (for example, lift 25-pound grandson onto shoulders without pain in time for July 4 family picnic).

4. Have a physician sign and date the POC within 30 days.

As we explain here, Medicare doesn’t require patients to obtain a physician’s referral or prescription to receive PT, OT, or SLP services. However, it does require that patients be under the care of a physician once treatment begins. This means that—unless your state practice act says otherwise—you can perform an initial evaluation and even begin treatment before getting an MD involved (thank you, direct access). You should only proceed with treatment, though, if you’re confident that you’ll be able to obtain a certified plan of care within that 30-day timeframe. Otherwise, you risk not receiving payment for your services. On that note, be sure to get a real or electronic signature—not a stamp.

5. Maintain good relationships with PT-friendly physicians.

The certifying physician does not have to be the patient’s primary care physician—and Medicare has no requirement that the patient see the certifying physician before that physician signs the POC (although the MD may have his or her own requirement to that end). That’s just one more reason to build a robust network of responsive physicians who understand the value of your services. That way, you can ensure there’s no delay on obtaining a signed POC—and thus, no delay on providing critical care to your patients.

6. Recertify plans of care before they expire (at least every 90 days).

As noted here, in order to continue providing care beyond the initial certification period, the therapist must have the physician recertify the plan of care before it expires. If you’re unable to obtain a recertification signature before the plan lapses, be sure to update the POC immediately and include an explanation for the delay in your documentation. (If you’re a WebPT Member, you can also use the Plan of Care report to see which POCs are pending certification and which require recertification.)

7. If a patient becomes Medicare-eligible mid-episode of care, establish a new POC.

Individuals who become newly eligible for Medicare during their course of care are considered new patients under Medicare, so you’ll need to establish a new certified plan of care and count the first visit post-eligibility change as visit number one. As we explain here, “while you'll need to evaluate the patient to complete the required reporting, you should not bill for an evaluation. Otherwise, you will continue treating the patient as normal.”

8. If a patient stops attending his or her therapy sessions, but returns after more than 60 days, establish a new POC.

As we write in this blog post, if a patient returns to therapy for the same issue after more than 60 days, you’ll want to treat it as a new case: perform an initial evaluation and create and certify a new plan of care.

There you have it: eight simple rules for creating a Medicare POC that adheres to Medicare’s exacting standards. Have your own rules for ensuring POC compliance in your practice? Share them in the comment section below. We’d love to hear them.

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