Page 177 - Medicare Benefit Policy Manual

• Diagnoses;

• Long term treatment goals; and

• Type, amount, duration and frequency of therapy services.

The plan of care shall be consistent with the related evaluation, which may be attached
and is considered incorporated into the plan. The plan should strive to provide treatment
in the most efficient and effective manner, balancing the best achievable outcome with
the appropriate resources.

Long term treatment goals should be developed for the entire episode of care in the
current setting. When the episode is anticipated to be long enough to require more than
one certification, the long term goals may be specific to the part of the episode that is
being certified. Goals should be measurable and pertain to identified functional
impairments. Therapists typically also establish short term goals, such as goals for a
week or month of therapy, to help track progress toward the goal for the episode of care.
If the expected episode of care is short, for example therapy is expected to be completed
in 4 to 6 treatment days, the long term and short term goals may be the same. In other
instances measurable goals may not be achievable, such as when treatment in a particular
setting is unexpectedly cut short (such as when care is transferred to another therapy
provider) or when the beneficiary suffers an exacerbation of his/her existing condition
terminating the current episode; documentation should state the clinical reasons progress
cannot be shown. The functional impairments identified and expressed in the long term
treatment goals must be consistent with those used in the claims-based functional
reporting, using nonpayable G-codes and severity modifiers, for services furnished on or
after January 1, 2013. (Reference: 42CFR410.61 and 42CFR410.105 (for CORFs).
NOTE: The regulatory requirements at 42CFR410.61 and 42CFR410.105 (for CORFs)
for the plan of care’s long-term goals to be consistent with functional impairments
identified for purposes of functional reporting, were removed by the CY 2019 Physician
Fee Schedule final rule, CMS-1693-F. Functional reporting and its associated
documentation requirements are no longer applicable for claims or medical records for
dates of service on and after January 1, 2019. See the NOTE at the beginning of Section
220.4 for more information.

The type of treatment may be PT, OT, or SLP, or, where appropriate, the type may be a
description of a specific treatment or intervention. (For example, where there is a single
evaluation service, but the type is not specified, the type is assumed to be consistent with
the therapy discipline (PT, OT, SLP) ordered, or of the therapist who provided the
evaluation.) Where a physician/NPP establishes a plan, the plan must specify the type
(PT, OT, SLP) of therapy planned.

There shall be different plans of care for each type of therapy discipline. When more
than one discipline is treating a patient, each must establish a diagnosis, goals, etc.
independently. However, the form of the plan and the number of plans incorporated into
one document are not limited as long as the required information is present and related to