Skip to Main Content

Print | Bookmark | Font Size: + | –

Fact Sheet


Outpatient Physical and Occupational Therapy Services: LCD L34049 - Fact Sheet

Plan of Care

For a comprehensive knowledge of policies related to therapy services, please reference the CMS Internet-Only Manuals and Local Coverage Determinations (LCDs) in the CMS Medicare Coverage DatabaseExternal Website.

See LCD L34049 -Outpatient Physical and Occupational Therapy Services and the billing and coding article (A57067) in the Associated Documents section.

All physical and occupational therapy (as well as speech-language pathology services) must be provided under a plan of care. There are requirements for both the plan of care and claim submission for these services. To designate the discipline associated with the plan of care, submit these services with the appropriate HCPCS modifier (note: one of these modifiers is REQUIRED with each therapy service submitted):

  • GN: Services delivered under an outpatient speech-language pathology plan of care
  • GO: Services delivered under an outpatient occupational therapy plan of care
  • GP: Services delivered under an outpatient physical therapy plan of care

Establishing the Plan - Services Must:

  • Relate directly and specifically to a written treatment plan.
  • Be established before treatment begins.
  • Be documented with the signature and professional designation (e.g., MD, OTR/L) of the person who established the plan and the date the plan was established.

Contents of Plan
At a minimum, the following information is required by regulation 42CFR424.24, 410.61, and 410.105(c):

  • Diagnoses
  • Long-term treatment goals (should be measurable and pertain to identified functional impairments)
  • Type (may be PT, OT, or SLP; where appropriate, the type may be a description of a specific treatment or intervention)
  • Amount (refers to number of times in a day the type of treatment will be provided)
  • Duration (number of weeks, or treatment sessions for THIS plan of care)
  • Frequency (number of times in a week the type of treatment is provided)

Significant Changes to the Therapy Plan

  • Changes are made in the patient’s record in writing and signed by the professionals responsible for the patient’s care.
  • A therapist may NOT significantly alter a plan established or certified by a physician/ NPP without that ordering physician/NPP’s documented written or verbal approval.
  • Obtain certification of the significantly modified plan within 30 days of the initial therapy treatment under the revised plan.

The plan shall be consistent with the related evaluation, strive to provide treatment in the most efficient and effective manner, and balance the best achievable outcome with appropriate resources.

Certification and Recertification

Reasonable and Necessary
To be considered reasonable and necessary, each of the following conditions must be met (this is a representative list of required conditions and doesn’t fully describe reasonable and necessary services):

The service is considered, under accepted standards of medical practice, to be a specific and effective treatment for the patient’s condition.

The service is of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist or under the supervision of a therapist.

Method and Disposition

  • Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.
  • The physician/NPP ordering the therapy should sign the plan of care. It isn’t appropriate for the physician/NPP to certify the plan of care if the patient didn’t need treatment or isn’t under that provider’s care.
  • The certification must include the date the ordering physician/NPP signs the document.
  • Certification MUST relate to treatment during the interval on the claim.
  • There’s no required, specific format for certifications or recertifications.

Initial Certification

Timely certification is met when the initial plan is documented with the physician/NPP’s signature or verbal order and dated within 30 days of the first day of treatment (including evaluation). If the order to certify is verbal, a signature within 14 days is timely.

For dates of service on or after January 1, 2025: When a patient is referred for rehabilitative therapy from a physician or NPP, the signature requirement for initial certification can be met by evidencing:

  1. A signed and dated order; and
  2. One-time transmission of the plan of care to the referring provider within 30 days of initial treatment

Recertification

  • Payment and coverage conditions require that the plan is reviewed as often as necessary but at least when it’s certified or recertified.
  • Recertifications that document the need for continued or modified therapy should be signed when the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan.

Delayed Certification

  • Should include any evidence the provider considers necessary to justify the delay.
  • For long delayed certification (over 6 months), the provider may choose to submit with the delayed certification some other document indicating the need for care and that the patient was under the care of a physician at the time of treatment (e.g., progress notes, order, telephone contact).
  • Reference: §1835(a) of the Act 42CFR424.11(d)(3)External Website

Since certification is a statutory requirement in SSA 1835(s)(2), payment denials based on the absence of certification is a technical denial (i.e., statutory requirement isn’t met).

Progress notes

  • Serves as documentation of ongoing medical necessity for therapy services.
  • Required on every 10th visit or at the time of significant change in clinical condition. Certifying physicians don’t need to sign progress notes.
  • Required to show measurable indicators of loss of function and the impact on patient’s life. Documentation should also show functional improvement, decline or any small changes that support ongoing medical necessity for therapy services.
  • Should support ongoing therapy beyond the number of visits recommended in the corresponding LCD.

Additional Information

  • Therapy caps and Advance Beneficiary Notices of Noncoverage (ABNs): Claims for therapy services that are denied because they aren’t considered reasonable and necessary (§1862(a)(1)(A)) or based on therapy caps (§1833(g)(1) or (g)(3)) are subject to consideration under the waiver of liability provision in §1879 of the Act. This means it’s appropriate, and you’re encouraged to, ask patients who are likely to receive services that exceed the therapy cap to sign an ABN.
    • If you obtained a signed, valid ABN and CGS (or another authorized contractor) requests additional supporting documentation, include a copy of the ABN with your other documentation.
    • Please see Beneficiary Notices Initiative | CMSExternal Website to access the standard ABN form and instructions.
  • Ensure medical records are signed: Please note that ALL services ordered or rendered to Medicare beneficiaries MUST be signed.

References

spacer

26 Century Blvd Ste ST610, Nashville, TN 37214-3685 © CGS Administrators, LLC. All Rights Reserved