Therapy Services

To meet CMS/Medicare requirements, clinicians must be familiar with the requirements for covered and payable outpatient therapy services as described in the manuals.

Required Documentation

The Plan of Care

• Evaluation/re-evaluation and plan of care
  • The plan of care must be established before treatment is begun. 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.
• The plan of care shall contain, at minimum, the following information:
  • Diagnoses
  • Long term treatment goals
    • Long term treatment goals should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care
  • Type
    • The type of treatment may be PT, OT, or SLP, or where appropriate the type may be a description of a specific treatment of intervention. Where a physician/NPP establishes a plan, the plan must specify the type of therapy planned.
  • Amount
    • The amount of treatment refers to the number of times in a day the type of treatment will be provided. Where amount is not specified, one treatment session a day is assumed.
  • Duration
    • The duration is the number of weeks, or the number of treatment sessions, for THIS PLAN of care.
  • Frequency
    • The frequency refers to the number of times in a week the type of treatment is provided. Where frequency is not specified, one treatment is assumed.
• Changes to the Therapy Plan
  • Changes are made in writing in the patient"s record and signed by one of the following professionals responsible for the patient"s care:
    • The physician/NPP
    • The physical therapist, occupational therapist, speech-language pathologist, the registered professional nurse or physician/NPP on the staff of the facility pursuant to the oral orders of the physician/NPP or therapist.

Treatment Notes

• Create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim.
• Notes should include:
  • Date
  • Identification of each specific intervention/modality
  • Total timed code treatment minutes and total treatment time in minutes
    • The time spent in evaluation shall not also be billed as treatment time.
    • Evaluation minutes are untimed and are part of the total treatment minutes, but minutes of evaluation shall not be included in the minutes for timed codes reported in the treatment notes.
  • Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each who contributed to that treatment
• Documentation should establish through objective measurements that the patient is making progress toward goals.
• Note that regression and plateaus can happen during treatment.
• It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus.

Certification/re-certifications

• Initial Certification of the Plan
  • The Physician/NPP certification of the plan (with or without an order) satisfies all of the certification requirements noted in 200.1 for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less. The initial treatment includes the evaluation that resulted in the plan.
• Timing of Initial Certification
  • The provider (e.g., physician/NPP, or therapist) should obtain certification as soon as possible after the plan of care is established, unless the requirements of delayed certification (listed below) are met. "As soon as possible" means that the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment.
  • Timely Certification is met when 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. A dated notation of the order to certify the plan should be made in the patient"s medical record.
• Review of Plan and Recertification
  • Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. It is not required that the same physician/NPP who participated initially in recommending or planning the patient"s care certify and/or recertify the plans.
  • Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed.
    • A physician/NPP may certify or recertify a plan for whatever duration of treatment the physician/NPP determines is appropriate, up to a maximum of 90 calendar days. It is expected that the physician/NPP should certify a plan that appropriately estimates the duration of care for the individual, even if it is less than 90 days.
    • Treatment beyond the duration certified by the physician/NPP requires that a plan be recertified for the extended duration of treatment.
• Restrictions on Certification
  • Certifications and recertifications by doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law. Optometrists may order and certify only low vision services. Chiropractors may not certify or recertify plans of care for therapy services.
• Delayed Certification
  • Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay. (Certifications are acceptable without justification for 30 days after they are due.)
  • Delayed certification should include one or more certifications or recertifications on a single signed and dated document.
  • Delayed certifications should include any evidence the provider considers necessary to justify the delay. (i.e., certification delayed because the physician did not sign it, or the original was lost)
  • Long delayed certification (over 6 months), the provider may choose to submit with the delayed certification some other documentation indicating need for care and that the patient was under the care of a physician at the time of the treatment (i.e., an order, progress notes, telephone contact, requests for certification, or signed statement of a physician/NPP)
• Denials Due to Certification
  • Denial for payment that is based on absence of certification is a technical denial, which means a statutory requirement has not been met. Certification is a statutory requirement in SSA 1835(a)(2)-('periodic review" of the plan).

Common Therapy Errors

• Notes fail to include time to support timed procedure codes
• No plan of care
• Plan of care lacks specific/measurable goals
• Plan of care lacks anticipated frequency and duration to reach goals
• Plan of care does not include all interventions used to help reach goals
• No orders documenting change in therapy
• Missing certification/recertification
• Goals exceed patient"s rehab potential
• Established goals met but therapy continuing for "conditioning" or "ongoing 1xwk"

Therapy Resources

• Certfication/recertification requirements
  • CMS Publication 100-2, The Medicare Benefit Policy Manual, Chapter 15, sections 220-230
• For documentation guidelines
  • CMS Publication 100-4, The Medicare Claims Processing Manual, Chapter 5, Section 20.2 et al
  • For determining units of time to report, etc
  • https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/IOM/list.asp