Required Elements of a Plan of Care

May 8, 2017
Rick Gawenda

Last week, I wrote an article titled “Who Can Sign a Medicare Therapy Plan of Care” and the week before, I wrote an article titled “Delayed Certification under Medicare Part B Therapy Services“. This week, I want to discuss what the required and optional components are for a plan of care for outpatient therapy services under Medicare Part B.

For outpatient physical, occupational and speech therapy services provided under Medicare Part B, the required components for a plan of care are the following:

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  1. There seems to be confusion in the “diagnoses” in the POC. Shouldn’t the POC diagnosis be WHY the patient is being treated -vs- only what’s on the physician referral?

    1. CMS states to indicate the diagnosis for which therapy services are being furnished. I would also recommend you read CMS Publication 100-04, Chapter 5, Section 10 – 20.3

  2. If you plan on treating the patient at the time of eval only and are enter the billing at that time for both the evaluation and the treatment, do you need to complete a POC since no futrther treatment will be requested?

    1. If you bill any treatment codes, you must have the physician or NPP sign and date the Medicare Part B therapy plan of care.

    1. There is no required format for a plan of care. If the evaluation contains all the components and is signed and dated by the therapist and physician/NPP, then that is fine.

  3. My group will often get a referral from a Physician for an established rehab protocol that covers an 11th month span. Often,(per their protocol)these patients are seen initially for 9 visits over a 2 month period. Then they are supposed to follow up with therapy again for 2 visit at 5 months, then again for 1 visit at 8 and 11 months. I understand we need to complete an initial POC that can be used for the first 90 days, but should the subsequent required POCs be initial or updated POCs? Not sure due to the length of time between the initial POC and the 5th month visits especially. Just want to make sure we are completing the necessary documents.

    1. The required elements for a plan of care are the same for an initial plan of care and an updated plan of care. Keep in mind that therapy is always based on the needs of the patient and not a protocol.

  4. Must a new plan of care for a recertification be written on the date of service of a patient’s visit or can the new plan of care be written as a non-visit note separately from the daily note?

  5. If you have “eval and treat” orders and an “eval only” is completed, with treatment also being performed during that session, are you required to have goals and a discharge summary in order to bill for both the eval and treatment during that one session?

    1. For a one-time visit, your plan would indicate you are discharging the patient. The one note would serve as the eval and DC.

  6. So it would be permissible to also bill for any treatment provided during that session as well?