The Centers for Medicare
& Medicaid Services (CMS), is continuing to focus on lowering the
Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one
area of concern identified in the CERT data is denial of outpatient
rehabilitation therapy services due to missing physician/non-physician
practitioner signature and dates on the certification of the plan of care. This
has led to Novitas Solutions, Inc recouping overpayments totaling over $164.70.
More importantly, when CMS and CERT extrapolate these errors to the universe
they will account for approximately $19.3 million in claims payment errors for
the November 2011 report.
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."
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, 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.
In order to avoid an error and the denial of services, when submitting
documentation for review, be sure to:
Have established 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 (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.
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