May 18, 2007
Comprehensive Error Rate Testing (CERT)
Documentation Tips for
Outpatient Therapy
Outpatient therapy services are payable only when furnished in accordance with certain conditions. The following conditions of coverage apply. The requirements noted (*) are also conditions of payment in 42CFR424.24© and according to the Act §1835 (a)(2)(D) are the three conditions that must be certified:
- Such services are or were required because the individual needed therapy services* (see §220.1.3); and
- A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP* (see §220.1.2); and
- Such services are or were furnished while the individual is or was under the care of a physician* (see §220.1.1); and
- Services must be furnished on an outpatient basis
- All of the conditions are met when a physician/NPP certifies an outpatient plan of care for therapy. Certification is required for coverage and payment of a therapy claim.
Outpatient Therapy Must be Under the Care of a Physician/Nonphysician Practitioners (NPP) (§220.1.1)
- An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician.
- The certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care, no further certification of the plan is required.
- 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.
- Establishing the 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. 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.
- Contents of Plan
The plan of care shall contain, at minimum, the following information:
- Diagnoses
- Long term treatment goals;
- Long term treatment goals should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care.
- Type;
- The type of treatment may be PT, OT, or SLP, or where appropriate the type may be a description of a specific treatment of intervention. Where a physician/NPP establishes a plan, the plan must specify the type of therapy planned.
- Amount;
- 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.
- Duration;
- The duration is the number of weeks, or the number of treatment sessions, for THIS PLAN of care.
- Frequency of therapy services;
- 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.
- Changes to the Therapy Plan
Changes are made in writing in the patient's record and signed by one of the following professionals responsible for the patient's 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)
- 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 verbal approval {See §220.1.2(C)}
Certification and Recertification of Need for Treatment and Therapy Plans of Care (§220.1.3)
- 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/NPP at the time of the treatment or if the patient did not need the treatment.
- Initial Certification of Plan
The physician's/NPP's certification of the plan for the first 30 days of treatment (with or without an order) satisfies all of the certification requirements for the first interval of 30 calendar days or 1 month of treatment.
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Review of Plan and Recertification
When services are continued for longer than 1 month, the physician/NPP who is responsible for the patient's care at that time should review and certify the plan for each interval of therapy. It is not required that the same physician/NPP order, certify and/or recertify the plans. Payment and coverage conditions require that the plan must be reviewed, dated and signed by a physician/NPP every 30 days to complete the certification requirements in 42CRF410.61(e).
