August 18, 2011
Outpatient Rehabilitation Therapy Services Reminders
Errors identified through the CERT review process:
- Missing/incomplete plan of care/treatment plan
- Missing physician/non-physician practitioner (NPP) signatures and dates
- Missing modality time
- Missing certification and recertification
Plan of Care, at a minimum, should contain
- Diagnoses
- Long-term treatment goals
- Short-term treatment goals
- Type of therapy – PT, OT, or SLP or a description of a specific treatment or intervention
- Frequency of therapy – number of treatment sessions in a day/week
- Duration of therapy – number of weeks or number of treatment sessions
- Signature and professional identity of person establishing the plan of care
- Date it was established
- Certification of physician/NPP
- Recertification every 90 calendar days
The Plan of Care should provide for treatment in the most effective and efficient manner for the best achievable outcome.
Avoiding CERT Errors
- Create a complete plan of care
- Document when the plan of care is modified, including how it has been modified and why the previous goals were not met or could not be met
- Confirm the plan of care is certified (recertified when appropriate) with physician/NPP signature and date
- Clearly document treatment time for timed codes and total treatment time (including times and untimed codes) in the patient's records
Resources
CMS Internet-Only Manuals (IOM): http://www.cms.gov/Manuals/IOM/list.asp
Definitions
related to Therapy Services: CMS IOM, Pub 100-2, Chapter 15, Section 220
Plan
of Care/Treatment Plan: CMS IOM, Pub 100-2, Chapter 15, Section 220.1.2
Certification/Recertification:
CMS IOM, Pub 100-2, Chapter 15, Section 220.1.3
