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Guide to Medicare’s Plan of Care Certification Compliance Requirements for Physical Therapy

Plan of Care Certification & Re-Certification Requirements are crucial for Medicare compliance

If you’re treating Medicare patients, it’s key that you understand and know how to navigate Medicare’s certification and re-certification requirements for plans of care. This blog post will take you through the ins and outs Understanding the requirements will help you feel confident in your compliance strategy and keep you out of the trouble!

The basics of progress notes

One of many Medicare requirements is each patient being seen by a PT/OT/SLP must be under the care of a physician or non-physician provider (NPP), e.g. APRN, PA, Certified Nurse Midwife. CMS considers a referral from a physician/non-physician provider (NPP) or the Plan of Care (POC) as the best ways to demonstrate physician involvement.

However these are not interchangeable. A referral by itself from a physician may not meet the requirements of a certifiable Plan of Care. It can only count as the certification as long as it has all the elements below are included in it. If it does not have all of them, you must send a separate document (Plan of Care, POC for short) that does include all the elements to the physician/NPP for their signature.

CMS says either a physician/NPP or physical therapist can establish the POC but if the therapist does it then physician/NPP must approve of the plan. That’s where the signing off on the plan of care by the physician/NPP affirms that the patient is under their care and they agree with the plan.

Required elements

A POC being sent for certification must contain ALL of the following elements to meet the requirements:

  • The date the plan of care being sent for certification becomes effective (the initial evaluation date is acceptable)
  • Diagnoses
  • Long term treatment goals
  • Type, amount, duration and frequency of therapy services
  • Signature, date and professional identity of the therapist who established the plan
  • Dated physician/NPP signature indicating either agreement with the plan or any desired changes.

The length of the certification period is the duration of treatment, e.g. 2x/week for 8 weeks. In this example the end date of the certification period is 8 weeks, to the day, from the initial evaluation date. In 2008 Medicare changed the requirement for the maximum duration of each plan of care. The maximum length of time any certification period used to be 30 days, however now it can run up to 90 days.

Setting an appropriate certification period

As a caution, you may raise a red flag if you make every POC certification for a 90 day period. Medicare knows not all patients require 90 days of rehabilitation. Claiming all your patients require the maximum time allowed may trigger an audit of your documentation. CMS recommends you set the duration for your certifications at your best estimate of the length of time it will take your patient to achieve their goals. For example, if you are treating a patient with a total knee arthroplasty and you feel you can achieve the patient’s long term goals in 8 weeks then that becomes your certification time.

Dealing with re-certifications

If you reach the end of the initial POC certification period and your patient has not accomplished all their goals or you and they believe they can continue to improve beyond the initial goals you must submit another POC to the physician/NPP for re-certification. CMS says this new POC must be sent out on or before the expiration date of the original certification. In actuality, if you have dated the Re-certification prior to the next visit of the patient following the ending of the original certification you are still in compliance.

The Re-certification must contain all the elements of the initial POC with any changes to the treatment plan, new goals, or explanations why the original goals were not achieved in the initial time frame. In short the new POC must lay out where you are going with the patient now. The same rules apply for the duration of the Re-certification as the original certification, it can be no longer than 90 days. At the end of this Re-certification, if the patient has not reached the goals and the care can still be considered to meet the medical necessity requirement then you need to repeat the Re-certification process again. This continues until your patient has achieved their goals or your care no longer meets the requirements for medical necessity at which point it’s time for discharge.

What happens if the doctor doesn't return a signed plan of care?

Medicare says you have 30 days from the date of the evaluation to get the certified POC back. If after 30 days it has not been returned, you need to demonstrate reasonable efforts to obtain it. That generally means you document your multiple efforts (recommend at least 3) to contact the office and/or you resent it several times and it still has not been returned. MWTherapy’s EMR with built-in e-fax makes it easy to create and fax your plan of care. CMS does get that not all physician offices are willing to assist with your compliance efforts and that you have no control over the physician’s actions. Medicare will exempt you from this requirement for this patient if you’ve demonstrated reasonable efforts.

For re-certifications the 30 day window to return the POC is not in effect – you should prepare and receive back a re-certified plan of care before the previous certification expires. As noted above the re-certification date must be on or before the end date of the previous certification.

Penalties for non-compliance

Failing to comply can have some significant consequences. If your Medicare Administrative Contractor were to decide to do a chart audit on your practice they would request some number of records for your Medicare patients. If, in the course of the audit, they find you do not have the Certifications/Re-certifications, if appropriate, included in the chart they can deem your care for that patient as not meeting the medical necessity or the requirement to be under a physician’s care. In that case Medicare can decide that all the care for these patients should not have been carried out and can ask for all payments plus interest and a penalty to be returned to them. This can come to a significant amount of money, especially if it occurs in a number of patient’s charts.

The bottom line

It is far better understand the regulations and to maintain your compliance by staying current with completing these notes rather than have to pay Medicare back. As noted previously, it is not likely that Medicare will be changing any of these rules soon. MWTherapy has the tools you need to document appropriately and send out your plans of care of efficiently and many compliance tools to keep you on track with Medicare.

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