Coverage/Documentation
requirements
If a physical therapy evaluation is signed by the physician, may it be used as
the certification?
The criteria for “timely certification” of the initial plan of therapy have
been met when the physician/non-physician practitioner’s certification of the
plan has been documented (by signature or verbal order) and has been dated
within the 30 days following the first day of treatment (including evaluation).
Certification requirements have been met when the physician has certified the
plan of care. If the signed order includes a plan of care, no further
certification of the plan is required.
Does Medicare require a prescription/order for therapy and the plan of
care to be signed by the physician?
An order for therapy services, 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. However, the plan of care differs in that the plan must be
certified. For example, if during the course of treatment -- under a certified
plan of care -- a physician sends an order for continued treatment for two more
weeks, then the order is acceptable as a certification to continue treatment
for that time period under that plan of care, which is considered to be
separate.
Are the documentation elements for the discharge summary the same as for the
progress report?
The progress report provides justification for the medical necessity of
treatment being provided. At a minimum, the progress report period is every 10
treatment days, or at least once during each certification interval or 30
calendar days, whichever is less. The discharge summary is required for each
episode of outpatient treatment and must cover the reporting period from the
last progress report to the date of discharge. The progress report includes an
assessment of improvement of the patient’s condition toward each goal and their
extent of progress; if there hasn’t been any improvement that needs to be noted
as well. The progress report should also include: any plans for continuing treatment;
reference to additional evaluation results; treatment plan revisions if
applicable; changes to long or short term goals; or discharge. The discharge
note can be the progress report written by the clinician.
