Eli's Rehab Report

Published on Fri Jan 18, 2008 PDF

Question: Are there limitations to the duration I can set for a plan of care with Medicare's new 90-day recertification period? For example, if I get a referral from an MD for therapy three times per week for eight weeks, I should set my plan of care for 8 weeks, right? But what if the patient misses one week due to illness -- do I have to establish a new POC when my initial POC's four weeks is up, even if I have only seen the patient for six visits?

Georgia Subscriber

Answer: A plan of care under Medicare can be no longer than 90 days, but you're free to vary your frequency within a certified POC as long as you do not exceed your original plan length. CMS Transmittal 88, which came out earlier this year, clarifies that "there is no restriction on the way duration of treatment or a certification interval may be expressed." You can read the full transmittal at www.cms.hhs.gov/Transmittals/downloads/R88BP.pdf.

Scroll to page 6 and see X-Ref Requirement Numbers 5921.10 and 5921.11.

Also, remember that while your physician referral sets a frame of reference, your exam and evaluation is what sets the POC, which includes frequency and duration of PT intervention, not the physician's referral.

Finally, take note that most other payers besides Medicare do not require that a physician sign and date your plan of care. Most payers only require a physician referral, and it is that frequency and duration on the referral that insurance companies will use upon a medical review to ensure the therapist completed no more visits than the physician specified. If, on a non-Medicare patient, the therapist sends a plan of a care to the physician for his signature, then that signed and dated plan of care will supersede the original referral. If you think about it, a signed plan of care contains all of the required elements of a physician referral. One national payer that does require that a physician sign and date your plan of care is Aetna.

Reader Questions were answered by Rick Gawenda, PT, director of PM&R at Detroit Receiving Hospital and owner of Gawenda Seminars & Consulting.