Therapy services must relate directly and specifically to a written treatment plan. The plan (also known as a plan of care or plan of treatment), must be established before treatment is begun. The plan is established when it is developed (e.g., written or dictated).
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.
Outpatient therapy services shall be furnished under a plan established by:
A physician/NPP (consultation with the treating physical therapist, occupational therapist, or speech-language pathologist is recommended. Only a physician may establish a plan of care in a CORF);
The physical therapist who will provide the physical therapy services;
The occupational therapist who will provide the occupational therapy services; or
The speech-language pathologist who will provide the speech-language pathology services.
It is acceptable to treat under two separate plans of care when different physician's/NPPs refer a patient for different conditions. It is also acceptable to combine the plans of care into one plan covering both conditions if one or the other referring physician/NPP is willing to certify the plan for both conditions. The Treatment Notes continue to require timed code treatment minutes and total treatment time and need not be separated by plan. Progress Reports should be combined if it is possible to make clear that the goals for each plan are addressed. Separate Progress reports referencing each plan of care may also be written, at the discretion of the treating clinician, or at the request of the certifying physician/NPP, but shall not be required by contractors.
Covered therapy services must:
Qualify as skilled therapy services;
Be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition;
Be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a qualified therapist;and
The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.
Therefore, therapy services are covered when they are rendered:
under a written treatment plan developed by the individual's physician, non-physician practitioners, optometrist, and/or therapist;
to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration; and
the patient's functional limitations are documented in terms that are objective and measurable.
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