(Medicare Benefit Policy Manual)

There shall be different plans of care for each type of therapy discipline.  When more than one discipline is treating a patient, each must establish a diagnosis, goals, etc. independently.  However, the form of the plan and the number of plans incorporate d into one document are not limited as long as the required information is present and related to each discipline separately.  For example, a physical therapist may not provide services under an occupational therapist plan of care.  However, both may be tr eating the patient for the same condition at different times in the same day for goals consistent with their own scope of practice.   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.  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.  If a scheduled holiday occurs on a treatment day that is part of the plan, it is appropriate to omit that  treatment day unless the clinician who is responsible for writing progress reports determines that a brief, temporary pause in the delivery of therapy services would adversely affect the patients condition.  The duration is the number of weeks, or the number of treatment sessions, for THIS PLAN of care.  If the episode of care is anticipated to extend beyond the 90 calendar day limit for certification of a plan, it is desirable, although not required, that the  clinician also estimate the duration of the entire episode of care in this setting.   The frequency or duration of the treatment may not be used alone to determine medical necessity, but they should be considered with other factors such as condition, progress, and treatment type to provide the most effective and efficient means to achieve t he patients goals.  For example, it may be clinically appropriate, medically necessary, most efficient and effective to provide short term intensive treatment or longer term and less frequent treatment depending on the individuals needs.   It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward an independent or caregiver assisted self -management program with the intent of improving outcomes and limiting treatment time.  For example, treatment may be provided 3 times a week for 2 weeks, then 2 times a week for the next 2 weeks, then once a week for the last 2 weeks.  Depending on the individuals condition, such treatment may result in better outcomes, or may result in earlier discharge than routine treatment 3 times a week for 4 weeks.  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.  Instead, the beginning and end frequencies shall be planned.  For example, amount, frequency and duration may be documented as once daily, 3 times a week tapered to once a week over 6 weeks.  Changes to the frequency may be made based on the clinicians clinical  judgment and do not require recertification of the plan unless requested by the physician/NPP.  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.   The above policy describes the minimum requirements for payment.  It is anticipated that clinicians may choose to make their plans more specific, in accordance with good practice.  For example, they may include these 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.  Also, notations in the medical record of beginning date for the plan are recommended but not required to assist  Medicare contractors in determining the dates of services for which the plan was effective.  C.  Changes to the Therapy Plan   Changes are made in writing in the patients record and signed by one of the following professionals responsible for the patients care:    The physician/NPP;    The physical therapist (in the case of physical therapy);    The speech -language pathologist (in the case of speech- language pathology services);    The occupational therapist (in the case of occupational therapy services); or    The registered professional nurse or physician/NPP on the staff of the facility pursuant to the oral orders of the physician/NPP or therapist.  While the physician/NPP may change a plan of treatment established by the therapist providing such services, the therapist may not significantly alter a plan of treatment established or certified by a physician/NPP without their documented written or verba l approval (see 220.1.3(C)).  A change in long- term goals, (for example if a new condition was to be treated) would be a significant change.  Physician/NPP certification of the significantly modified plan of care shall be obtained within 30 days of the initial therapy treatment under the revised plan.  An insignificant alteration in the plan would be a change in the frequency or duration due to the patients illness, or a modification of short -term goals to adjust for improvements made toward the same long- term goals.  If a patient has achieved a goal and/or has had no response to a treatment that is part of the plan, the therapist may delete a specific intervention from the plan of care prior to physician/ NPP approval.  This shall be reported to the physi cian/NPP responsible for the patients treatment prior to the next certification.   Procedures (e.g., neuromuscular reeducation) and modalities (e.g., ultrasound) are not goals, but are the means by which long and short term goals are obtained.  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 patients disease or condition or adjustments to the plan due to lack of expected response to the planned intervention, when the goals remain unchanged.  Only when the patients condition changes significantly, making revision of long term goals necessary, is a physicians/NPPs signature required on the change, (long term goal changes may be accompanied by changes to procedures and modalities).  220.1.3 - Certification and Recertification of Need for Treatment and Therapy Plans of Care  (Rev. 88, Issued: 05-07- 08, Effective: 01 -01-08, Implementation: 06-09-08)  Reference:  42CFR424.24(c)   See specific certification rules in Pub. 100-01, chapter 4, 20  for hospital services.  A.  Method and Disposition of Certifications  Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.  It is not appropriate for a physician/NPP to certify a plan of care if the patient was not under the care of some physician/NP P at the time of the treatment or if the patient did not need the treatment.  Since delayed certification is allowed, the date the certification is signed is important only to determine if it is timely or delayed.  The certification must relate to treatmen t during the interval on the claim.  Unless there is reason to believe the plan was not signed appropriately, or it is not timely, no further evidence that the patient was under the care of a physician/NPP and that the patient needed the care is required.   The format of all certifications and recertifications and the method by which they are obtained is determined by the individual facility and/or practitioner.  Acceptable documentation of certification may be, for example, a physicians progress note, a physician/NPP order, or a plan of care that is signed and dated by a physician/NPP, and indicates the physician/NPP is aware that therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan when there is evidence the plan was sent (e.g., to the office) or is available in the record (e.g., of the institution that employs the physician/NPP) for the physician/NPP to review.  For example, if during the course of treatment under a certified plan of care a physician send s an order for continued treatment for 2 more weeks, contractors shall accept the order as certification of continued treatment for 2 weeks under the same plan of care.  If the new certification is for less treatment than previously planned and certified, this new certification takes the place of any previous certification.  At the end of the 2 weeks of treatment (which might extend more than 2 calendar weeks from the date the order/certification was signed) another certification would be required if furthe r treatment was documented as medically necessary.   The certification should be retained in the clinical record and available if requested by the contractor.   B.  Initial Certification of Plan   The physicians/NPPs certification of the plan (with or without an order) satisfies all of the certification requirements noted above in 220.1 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 or supplier (e.g., facility, physician/NPP, or therapist) should obtain certification as soon as possible after the plan of care is established, unless the requirements of delayed certification 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.  Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is established.  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.   Timely certification of the initial plan is met when physician/NPP 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 patients medical record.  Recertification is not required if the duration of the initially certified plan of care is more than the duration (length) of the entire episode of treatment.  C.  Review of Plan and Recertification  Reference:  42CFR424.24(c) , 1861(r), 42CFR 410.61(e).  The timing of recertification changed on January 1, 2008.  Certifications signed on or after January 1, 2008, follow the rules in this section.  Certifications signed on or prior to December 31, 2007, follow the rule in effect at that time, which required rece rtification every 30 calendar days.  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 patients 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 ar e delayed.   Physician/NPP Options for Certification.   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.  Many episodes of therapy treatment last less than 30 calendar days.  Therefore, 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.  If the therapist writes a plan of care for a duration that is more or less than the duration approved by the physician/NPP, then the physician/NPP would document a change to the duration of the plan and certify it for the duration the physician/NPP finds appropriate (up to 90 days).  Treatment beyond the duration c ertified by the physician/NPP requires that a plan be recertified for the extended duration of treatment.  It is possible that patients will be discharged by the therapist before the end of the estimated treatment duration because some will improve faster than estimated and/or some were successfully progressed to an independent home program.  Physicians/NPPs may require that the patient make a physician/NPP visit for an examination if, in the professionals judgment, the visit is needed prior to certifying the plan, or during the planned treatment.  Physicians/NPPs should indicate their require ment for visits, preferably on an order preceding the treatment, or on the plan of care that is certified.  If the physician wishes to restrict the patients treatment beyond a certain date when a visit is required, the physician should certify a plan only until the date of the visit.  After that date, services will not be considered reasonable and necessary due to lack of a certified plan.  Physicians/NPPs should not sign a certification if they require a visit and a visit was not made.  However, Medicare does not require a visit unless the National Coverage Determination (NCD) for a particular treatment requires it (e.g., see Pub. 100-03, 270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds).  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.   D.  Delayed Certification