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Patients with Medicare using PT

“Services were required because the individual needed therapy services”

For a person to need therapy services, they must have a plan of care certified as necessary by a physician or other referring professional.

“A plan for furnishing such services has been established by a physician/NPP or by a therapist providing such services and is Eperiodically reviewed by a physician/NPP”

A PT is allowed to establish a plan of care for patients, but the insurance doesn’t necessarily have to pay for it. In order for Medicare to pay for a plan of care that is established by a physical therapist, a physician or other referring provider must sign off on that plan of care.

“Services are or were furnished while the individual is or was under the care of a physician…In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above conditions are met. Certification is required for coverage and payment of a therapy claim.”

If a physician/NPP provides a referral at the time of evaluation, this ensures that the patient was under the care of a referral source at the time of the evaluation. This becomes important because there are patients that will wait to start therapy for months or years after a referral was issued. There is not guarantee that the referral source will certify the POC at this later date. If this POC is not certified, then the treatment will not be covered by Medicare.

“Claims submitted for outpatient PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care”

Although this is a technicality, this may cause a denial of payment if the NPI number, of the referring professional, is not included on claims.

“Although there is no Medicare requirement for an order, when documented in the medical record, an order provided evidence that the patient both needs therapy services and is under the care of a physician. The certification requirements are met when the physician certifies the plan of care”

Again, this needs to be reiterated over and and over, the patient needs to be under the care of a physician when in physical therapy. The referral can serve to show that the patient was under the care of a physician at the time of the initial evaluation. In the end, the only thing that matters is that the physician/NPP signs off on the plan of care established by the PT.

“Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan”

Have you had enough of this yet.

Do you think that there is a reason this is spelled out so frequently in the documentation?

Some don’t follow the rules of the game.

“The services must relate relate directly and specifically to a written treatment plan as described…must be established before treatment is begun…written or dictated.”

We all know that a plan is required.

Some don’t know how to write frequency and duration.

Some don’t know how to write interventions, or some perform interventions not written.

They must be written and signed off on in order to perform.

“The signature and professional identity of the person who established the plan, and date it was established must be recorded with the plan”

No brainer…or is it?

Stamped signatures are not signatures according to CMS, and stamps are not approved.

“Outpatient therapy services shall be furnished under a plan established by:

A physician/NPP

The physical therapist who will provide the physical therapy services”

This is critical. A therapist doesn’t need to have a POC signed if the physician/NPP creates the plan and it is abided by the PT verbatim.

Also, the PT doesn’t need to be licensed if practicing under a physician.

“The plan may be entered into the patient’s therapy record either by the person who established the plan or by the provider’s or supplier’s staff when they make a written record of that person’s oral orders before treatment is begun.”

This is a formality, but it has to do with dictating a note. Treatment can not be started by anyone other than the PT or immediately supervised by the PT that created the plan, before it is entered into record.

“The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.”

I tend to do one billable unit on the days of an evaluation. This is based on how much time you spend with the patient covering an intervention, or if an untamed intervention is performed.

“Therapy may be initiated by qualified professionals or qualified personnel based on a dictated plan. Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who established the plan”

This means that the PT or PTA can start treatment on the initial visit. The PT must be in the office supervising the PTA at this point.

Some people, like Anthony Maritato, use this method to establish a relationship between the treating therapist and the patient.

Others, like Rick Gawenda, find this to be a less efficient use of time.

“It is acceptable to treat under two separate plans of care when different physicians/NPP 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”

I’ve seen some clinic totally prefer to treat the patient 2x/week for one ailment and 2x/week for another ailment.

Take a guess why…it sure ain’t for the patient’s benefit.

Medicare limits how many units can be charged in a session (essentially how much money can be paid in a session). If there is a way around this, you can bet that money hungry clinics will find this workaround.

“The plan of care shall contain, at minimum, the following information as required by regulation:

Diagnosis

Long term goals

Type amount and frequency of therapy services”

The evaluation doesn’t need much. It would be great if it established medical necessity, but is it required…NOPE!

The diagnosis can either be ICD codes or the written diagnosis since it is not spelled out.

“Long term treatment goals should be developed for the entire episode of care in the current setting”

This is something new to many therapists. Medicare doesn’t specifically require short term goals. If they are not required, do they need to be done? In school it is taught to set short term goals as a step towards the long term goal. In reality, every minute counts. The time spent creating and typing short term goals could be used elsewhere. Creating short term goals is literally robbing Peter to pay Paul, but Paul doesn’t need the money.

“…long term goals may be specific to the part of the episode that is being certified. Goals should be measurable and pertain to identified functional impairments”

Goals should be measurable and timely. They should relate to function. There is a lot of grey area in this portion. Subjective measurements are not the most reliable and maybe shouldn’t be used in goal writing.

I see frequently “to increase hip abduction strength to 4/5”

This goal is measurable, albeit loosely and has no tie to function.

I personally like to use outcome measures and specific functional testing in my goal writing. For instance, the patient will improve the (TUG, Tinetti, Berg, chair rise, single leg stance, lower/upper extremity functional scale, yellow flag risk form) in order to …

“…documentation should state the clinical reasons progress cannot be shown”

This is built into many EMRs now.

Sometimes I will write that the symptoms are not reducible through movement or modulation. Other times, I will write that the patient is not consistent with the HEP. Sometimes, it’s that it is a maintenance case and the patient is unsafe to perform exercises with an untrained professional due to fall risk, BP fluctuations or rapidly changing SpO2.

This is where it really pays off to have read some of the textbooks that were recommended in PT school. I particularly recommend the ACSM handbook.

“The amount of treatment refers to the number of times in a day the type of treatment will be provide…one treatment session a day is assumed”

In an outpatient setting, this is typically one. In an acute or subacute setting it may be BID (twice in a day) or even TID (thrice in a day).

“The frequency refers to the number of times in a week the type of treatment is provided”

I struggle with this one. Many therapists are putting 3 times per week for 4 weeks on all their plans. This isn’t being done because they believe it’s what is best for the patient, but because there is a corporate policy to get as many visits in per week as able.

I get frustrated with this type of plan. If you are a therapist and working in this setting, but only putting this plan down to keep from rocking the boat…you are abusing Medicare and should call CMS to report this activity.

Please and thank you.

“The duration is the number of weeks, or the number of treatment sessions, for THIS plan of care.”

This question is asked frequently. I will typically put down the number of weeks if I know that the surgeon only wants so many weeks of PT per a protocol. If it is not protocol based, the. I will typically put down the total number of visits expected for the episode.

Many of my patients (>80%) require an authorization and are typically given 12 visits to start. In this case, I will make the plan for 12 visits or 90 days, whichever comes sooner. I know that I have to do a progress note and get a recertification and ask for more visits at this time anyways.

“It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward and independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time.”

Again, I frequently get 12 visits to start. I try to make these visits as worthwhile for the patient as possible. For some cases I will see 3 times per week, but for many I will see 1 visit per week or 2 per 10 days. This way we are able to see the patient for the timeline of change that is expected. For instance, strength usually occurs in the first 6 weeks due to neuromuscular changes and hypertrophy happens after this timeframe. If we are seeing the patient for 12 visits in 4 weeks, then we may have exhausted the benefits before noting the change.

To me, that is a waste. Many patients agree with me on this because we make the POC together based on their finances (copays need to be paid each day regardless of how many times you are seen per week), work schedules and need/expectation to change over a given time period.

Again…PTs, if you don’t have this autonomy to create your own Plan of Care, are you truly an autonomous practitioner or are you simply a technician that is doing what a higher figure is telling you to do?

“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”

This is one of the aspects that I take advantage of in the plan. At this point, I will write 12 visits over 12 weeks or 12 visits over 6 weeks. This way I may start at 3 visits and taper down to one visit per week.

“The clinician should consider any comorbidities, tissue healing, the ability of the patient and/or caregiver to do more independent self-management as treatment progresses, and any other factors related to frequency and duration of treatment”

I had a patient that hadn’t walked in years. The person had fluctuating blood pressures with activity and at times therapy was halted due to elevated BP. This patient was not safe to perform gait training independently due to fall risk and intermittent cardiac crises. This patient was treated 1-2 times per week with gait training and performed a Nu Step at home. The interventions that were skilled were performed in the clinic and the unskilled interventions were issued for HEP.

“…optional elements: short term goals, goals and duration for the current episode of care, specific treatment interventions, procedures, modalities or techniques and the amount of each.”

As much as this says “optional”, I’m not sure it is fully optional. For instance, this report notes that a therapist did not have the type of intervention in his POC as one of many reasons for repayment.

“Changes to procedures and modalities do not require physician signature when they represent adjustments to the plan that result from a normal progression in the patient’s disease or condition or adjustments to the plan due to the lack of expected response unchanged. Only when the patient’s condition changes significantly, making revision of term goals necessary, is a physician/NPP’s signature required on the change.”

For me personally, when there is a major change in status that requires a change in goals and expectations, I phone the physician and alert the medical team to the change in status. I feel that it is important to relay this information to the physician personally, in addition to writing a progress note or re-evaluation.

“Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care… The date of the certification is signed is important to determine if it is timely or delayed”

This small detail is important. Although the physician may sign it, it also must be dated. I’ve had to send many evaluations back for a date.

“The physician/NPP’s certification of the plan satisfies all of the certification requirements noted above in (section) 220.1 for the duration of the plan of care, or 90 calendar days from the date of the initial evaluation, whichever is less.”

This is where things get confusing. If you set your plan for 90 days, then everything is good and no confusion.

If you set your plan for 6 weeks, then you would need to get another certification past 6 weeks.

I’ve seen some therapists just write the plan for 90 days on each evaluation in order to check the 90 day box. Don’t be that person. Put thought into your plan and don’t just set up your plan for 90 days because it’s the maximal allowable in one episode.

My duration varies from 4 weeks for acute back pain, 6 weeks for vestibular dizziness up to 12 weeks for neurological disorders. The only downside of doing this is that there is paperwork more frequently. The upside is that it forces a reassessment, which indicates whether or not a patient is responding to care.

“…the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment.”

At my clinic, we have a spreadsheet that has the evaluation name, date and signature (yes/no). Once the signature is obtained, the name is removed from the spreadsheet.

Also, when discharging a chart we have a checklist of items that are expected to be in the chart. The signed evaluation is one of these items on the checklist.

“Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification”

Again, this is more of a standard operating procedure. When a note is faxed to a physician, the fax cover letter becomes a part of the record. This is done to demonstrate that due diligence was performed in attempting to get a note signed.

“Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or re-certified to complete the certification requirements. It is not required that the same physician/NPP who participated initially in recommending and planning the patient care certify and/or re-certify the plans”

This is also an opportunity for PTs. If a patient has a better relationship with the PCP compared to the orthopedic surgeon, it may be prudent to have the patient get the PCP to sign off on the recertification.

“If the physician wishes to restrict the patient’s treatment beyond a certain date when a visit is required, the physician should certify a plan only until the date of the visit.”

The evaluation template that we use from Theraoffice provides an area for the physician to change the plan if deemed appropriate.

“Certifications and recertification’s 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… Chiropractors may not certify or recertify plans of care for therapy services.”

This is huge. For instance, a podiatrist physician is only allowed to write a referral for their scope of practice. Seeing a patient from a podiatrist for an ailment that is outside of the scope of practice may result in a sticky situation, like Seinfeld encountered.

Also, Chiropractic physicians are not allowed to certify plans of care for PT. This applies to Medicare. You must be aware of the patient’s insurance in order to determine if other insurances have the same regulations.

“… The provider is precluded from charging the beneficiary for services denied as a result of missing certification”

This means that the provider or company that the provider work for will hound the physician’s office to get the evaluation or progress report signed. Otherwise, the amount paid was not approved to be performed.

The clinics are not allowed to charge the patient due to a lack of certification.

This is not meant to be legal advice, as this is my take on the Important passages from This manual regarding our profession.

If in need of more information on Medicare compliance, check out Nancy Beckley or Rick Gawenda

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