Don’t Get Tripped Up by Therapy Plan of Care and Certification Requirements

One of the most common errors I see when reviewing therapists’ documentation is also one of the most easily rectified.  Too often, therapists either neglect to update their plans of care for Medicare beneficiaries on a timely basis or fail to have those plans of care certified by a physician.  Failure to do either of these can result in a denial of services.

Earlier this summer, CMS published a fact sheet titled “Complying with Medical Record Documentation Requirements” that was developed by the Medicare Learning Network (MLN) in conjunction with the Comprehensive Error Rate Testing (CERT) and Medicare Administrative Contractor (MAC) Outreach and Education Task Forces.  The document, which can be found here, summarizes some of the more common procedures that have resulted in insufficient documentation errors in various health care settings.  One of the areas highlighted references the establishment and certification of physical therapy plans of care.  Specifically, the document states “Documentation did not support certification of the plan of care for physical therapy services.  The physician/non-physician practitioner’s (NPP) signature and date of certification of the plan of care or progress note indicated the physician/NPP reviewed and approved the plan of care is required.”  The document goes on to provide links to the pertinent sections of Chapter 15 of the Medicare Benefit Policy Manual which address plans of care as well as certifications and re-certifications.

This guidance comes on the heels of a resource released last year by the CERT A/B MAC Outreach and Education Task Force designed to educate providers on these and other common documentation errors which often resulted in insufficient documentation.  Specifically, this resource (an example of which can be found here) addresses therapy plans of care, signature and certification of the plan, treatment notes, and functional reporting.  It is no coincidence that the components mentioned in the guide are among the most commonly deficient areas I see when reviewing therapists’ documentation.  Today’s post will highlight some key points pertaining to plans of care and certifications.  We will look into treatment notes, progress reports, and functional reporting in the next blog post.

Contents of plan of care

As pointed out by the online guide and referenced in the Medicare Benefit Policy Manual, the therapy plan of care should contain, at a minimum, the following:

• Diagnosis
• Long term treatment goals – (Expected outcomes for the entire episode of care.)
• Type of therapy – (When more than one discipline, e.g. PT and OT, is treating a patient, each must establish a plan of care independently. A PT cannot provide services under an OT plan of care, and vice versa.)
• Duration – (Number of weeks or number of treatment sessions for this plan of care.)
• Frequency – (Number of times per week the type of treatment is provided. When frequency is not specified, one treatment per week is assumed. When tapered frequency is planned, the exact number of treatments per frequency level is not required to be projected in the plan, because the changes should be made based on assessment of daily progress. Instead, the beginning and end frequencies shall be planned. For example, amount, frequency and duration may be documented as “once daily, 3 times a week tapered to once a week over 6 weeks”. Changes to the frequency may be made based on the clinicians clinical judgment and do not require recertification of the plan unless requested by the physician/NPP.)

Signature and certification of the plan of care

The legible signature and professional identity of the individual who established the plan, as well as the date it was established, must be recorded with the plan.  A physician or NPP must certify and date the plan of care.  Per the Medicare Benefit Policy Manual, acceptable documentation of certification may be, for example:

• Physician’s or NPP’s progress note
• Physician or NPP’s order
• Plan of care that is signed and dated by a physician/NPP
• Documentation must indicate that the physician/NPP is aware that the therapy service is or was in progress and agrees with the plan when there is evidence the plan was sent to the physician/NPP or is available in the patient’s medical record for the physician/NPP to review.

In my opinion, the best method of certification is for the physician to sign and date the plan of care established by the therapist.  Plans of care are often included in documentation requests and having a certified plan of care that is signed and dated by the physician/NPP is a good thing to have when submitting your records.  Furthermore, it can be difficult tracking down physician progress reports, and orders are often not very descriptive.

The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of the certification requirements for the duration of the plan of care or 90 calendar days from the date of the initial treatment, whichever is less.  Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation).  If the order to certify is verbal, it must be followed within 14 days by a signature to be timely.  Treatment beyond the duration certified by the physician/NPP requires that a plan be recertified for the extended duration of treatment.

Insufficient documentation of certified plans of care is one of the most common errors identified by CMS, but with proper tracking of plan durations and need for re-certifications,  this is one relatively “black and white” documentation requirement that most providers should be able to meet.