Plan of Care Requirements
The Centers for Medicare & Medicaid Services (CMS) is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate and one area of concern is missing physician/non-physician practitioner signature and dates on the certification of the plan of care.
After analyzing the CERT data, denial of outpatient rehabilitation therapy services due to missing signatures and dates has lead to CMS recouping over-payments totaling over $164.70. When CMS and CERT extrapolate these errors to the universe, they account for approximately $19.3 million in claims payment errors for the November 2011 report. With Congress pressuring CMS to reduce fraud and overspending, CMS is relying heavily on the CERT data to find problem areas that will allow them to recoup larger sums of over-payment.
Medicare defines rehabilitative services as those services that lead to "recovery or improvement in function and, when possible, restoration to a previous level of health and well-being."
What is a Plan of Care
Outpatient rehabilitation therapy services must relate directly to a written treatment plan (also known as the plan of care or plan of treatment). Medicare states "the plan of care shall contain, at minimum, the following information: diagnoses, long term treatment goals, and type, amount, duration, and frequency of therapy services."
The plan of care is established by a physician, non-physician practitioner, physical therapist, an occupational therapist, or a speech-language pathologist. The signature and professional identity of the person who established the plan of care and the date it was established must be documented within the plan of care. The plan of care must be established before the therapy treatment can begin.
Establishing the plan of care is different than certifying the plan of care. Medicare states that certification of the plan of care requires a dated signature on the plan of care, or some other document, by the physician or non-physician practitioner who is the primary care provider for the patient.
In the absence of a formal certification document, a physician progress note indicating the physician's agreement with the plan of care is acceptable. The certification of the plan of care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment.
Payment may be denied if the physician does not certify the plan of care; therefore, the therapist should forward the plan to the physician as soon as it is established.
Recertification of the plan of care, which also requires a physician or non-physician signature and date, should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification.
A therapy provider, per Medicare rules, may obtain a verbal order for certification or recertification of the plan of care; however, the verbal order must be signed and dated by the physician/non-physician practitioner within 14 calendar days.
Medicare and other insurance companies are getting very strict about the plan of treatment and we are seeing many more denied claims due to invalid plans of treatment or failing to recertify the plan of treatment within the above mentioned time frames.
Documentation to Review
In order to avoid an error and the denial of services, when submitting documentation for review, be sure to:
- Establish a complete initial plan of care, making certain to include your signature, your professional identification (i.e. PT, OT, etc.), and have the date the plan was established.
- Ensure that the plan of care is certified (and recertified when appropriate) with a physician/non-physician practitioner signature and date.
- Clearly document when the plan of care has been modified, including how it was modified and why the previous goals could not be met.
- Establish a system where you can track when the plan of treatment was sent to the physician/non-physician practitioner and when it was received back with a proper signature and date. You must follow-up on any plans that are not returned in a timely manner.
Plan of Care References:
- CMS Internet Only Manual, Publication 100-02, Chapter 15, section 220
- CMS Internet Only Manual, Publication 100-04, Chapter 5, section 20
So be sure to check your current plan of care records and verify that you are in compliance to avoid an audit and costly repayment penalties.