Page 175 - Medicare Benefit Policy Manual

• Claims submitted for outpatient (and CORF) PT, OT, and SLP services must
contain the required functional reporting. (See 42CFR410.59, 60, and 62), Pub.
100-04, Medicare Claims Processing Manual, chapter 5, section 10.6.) NOTE:
The applicable regulatory provisions were removed through the CY 2019 PFS
final rule, CMS-1693-F. Functional reporting requirements are no longer
applicable for claims for dates of service on and after January 1, 2019. See the
NOTE at the beginning of Section 220.4 for more information.

The patient functional limitations(s) reported on claims, as part of the functional
reporting, must be consistent with the functional limitations identified as part of the
therapy plan of care and expressed as part of the patient’s long term goals* (see
42CFR410.61, 42CFR410.105, Pub. 100-04, Medicare Claims Processing Manual,
chapter 5, section 10.6.) NOTE: The applicable regulatory provisions were removed
through the CY 2019 PFS final rule, CMS-1693-F. Functional reporting and its
documentation requirements are no longer applicable for claims or medical records
for dates of service on and after January 1, 2019.

220.1.1 - Care of a Physician/Nonphysician Practitioner (NPP)
(Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)

Although there is no Medicare requirement for an order, when documented in the medical
record, an order provides evidence that the patient both needs therapy services and is
under the care of a physician. The certification requirements are met when the physician
certifies the plan of care. If the signed order includes a plan of care (see essential
requirements of plan in §220.1.2), no further certification of the plan is required.
Payment is dependent on the certification of the plan of care rather than the order, but the
use of an order is prudent to determine that a physician is involved in care and available
to certify the plan.

(The CORF services benefit does not recognize an NPP for orders and certification.)

220.1.2 - Plans of Care for Outpatient Physical Therapy, Occupational
Therapy, or Speech-Language Pathology Services
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)

Reference: 42CFR 410.61 and 410.105(c) (for CORFs)

A. Establishing the plan (See §220.1.3 for certifying the plan.)

The services must relate directly and specifically to a written treatment plan as described
in this chapter. The plan, (also known as a plan of care or plan of treatment) must be
established before treatment is begun. The plan is established when it is developed (e.g.,
written or dictated).

The signature and professional identity (e.g., MD, OTR/L) of the person who established
the plan, and the date it was established must be recorded with the plan. Establishing the