Recertifications and plans of care - HELP

November 7, 2008

Recert question - I have been debating this with a colleague for some time and

would appreciate anyone's input. I do not confidently know the answer now. I am

in the outpatient setting in a direct access state. With Medicare's new

recertification period of 90 days, a colleague of mine feels that if he sets a

frequency of 2x a week for 4 weeks in his plan of care, he can take up to 6

weeks or 8 weeks to get in his (8 visits). My understanding is that I am limited

to the total visit frequency AND the duration of my plan of care. So if a

patient misses one week for example due to illness, I must establish a new plan

of care when my initial POC's 4 weeks is up, even if I have only seen the

patient 6 visits. Am I incorrect?

Plan of care question - Are there limitations to the duration I can set a plan

of care? If I get a referral from an MD for 3x/wk for 8 weeks, can I set my plan

of care for 8 weeks? Is there a limitation with private insurance? Is there a

limitation with Medicare?

Bisesi MPT COMT

Winter Haven, FL

November 7, 2008

-

In brief-

Under Medicare the plan of care can be no longer than 90 days but there can be

considerable variability within that certified plan of care so long as you do

not exceed your original length of plan ( e.g 8 weeks of 12 weeks or 12 visits

total or 30 visits total). The other thing to note is that Medicare does expect

to see a tapering of visits toward discharge.

I would like to address the last part of your question, if I may. The referral

from the physician is the entry point and a frame of reference. But it is your

exam and evaluation that sets the PT plan of care which includes frequency and

duration of PT intervention, NOT the physician's referral. Under Medicare the

physician may chose to certify your plan for something different from what you

originally recommended. In that case. if you need to go beyond what is

originally certified ( after you do your eval) then you have to get additional

certification, if Medicare is going to pay for it.

There is great information on this on the APTA website. I have pasted a section

of Medicare's Transmittal 88 below which should answer your questions.

Since most/many insurance's follow Medicare guidelines, we use Medicare's

framework unless we know otherwise. Of course Workers Comp and some HMOs are

entirely different and you have to be vigilant for their requirements.

However....

" There is no restriction on the way duration of treatment or a certification

interval may be expressed. Variations may include e.g., calendar days, number of

treatment sessions, or number of weeks of treatment. Contractors shall interpret

the certification interval using the longest of the durations in the plan. As

long as the physician approves the plan and the plan does not extend more than

90 calendar days from the first treatment day of that plan, the certification is

acceptable for either the number of treatments, the number of weeks, or the

number of calendar days that represent the longest interpretation of the

duration of treatment. For example, if a plan is written and certified for

3x/week x 4 weeks and the patient receives treatment 3/xweek for 3 weeks but is

absent the 4th week, then the planned 4th week of treatment is still certified

if it is delivered later, assuming the plan remains appropriate and the

treatment remains skilled and necessary. Or, under the same circumstances the

plan is still certified when it includes treatment 4 times the first week and 2

times the last week. A reasonable amount of variation in the plan is

acceptable. "

Marcy Stalvey, PT, NCS

Akron General Edwin Shaw Rehab

Akron, OH 44312

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