Page 179 - Medicare Benefit Policy Manual

The above policy describes the minimum requirements for payment. It is anticipated that
clinicians may choose to make their plans more specific, in accordance with good
practice. For example, they may include these optional elements: short term goals, goals
and duration for the current episode of care, specific treatment interventions, procedures,
modalities or techniques and the amount of each. Also, notations in the medical record of
beginning date for the plan are recommended but not required to assist Medicare
contractors in determining the dates of services for which the plan was effective.

C. Changes to the Therapy Plan

Changes are made in writing in the patient’s record and signed by one of the following
professionals responsible for the patient’s care:

• The physician/NPP;

• The physical therapist (in the case of physical therapy);

• The speech-language pathologist (in the case of speech-language pathology
services);

• The occupational therapist (in the case of occupational therapy services); or

• The registered professional nurse or physician/NPP on the staff of the facility
pursuant to the oral orders of the physician/NPP or therapist.

While the physician/NPP may change a plan of treatment established by the therapist
providing such services, the therapist may not significantly alter a plan of treatment
established or certified by a physician/NPP without their documented written or verbal
approval (see §220.1.3(C)). A change in long-term goals, (for example if a new
condition was to be treated) would be a significant change. Physician/NPP certification
of the significantly modified plan of care shall be obtained within 30 days of the initial
therapy treatment under the revised plan. An insignificant alteration in the plan would be
a change in the frequency or duration due to the patient’s illness, or a modification of
short-term goals to adjust for improvements made toward the same long-term goals. If a
patient has achieved a goal and/or has had no response to a treatment that is part of the
plan, the therapist may delete a specific intervention from the plan of care prior to
physician/ NPP approval. This shall be reported to the physician/NPP responsible for the
patient’s treatment prior to the next certification.

Procedures (e.g., neuromuscular reeducation) and modalities (e.g., ultrasound) are not
goals, but are the means by which long and short term goals are obtained. Changes to
procedures and modalities do not require physician signature when they represent
adjustments to the plan that result from a normal progression in the patient’s disease or
condition or adjustments to the plan due to lack of expected response to the planned
intervention, when the goals remain unchanged. Only when the patient’s condition
changes significantly, making revision of long term goals necessary, is a