Clarification for SNF Therapy POC's

[Guest guest]

Can anyone provide a reference to the regulation that requires the Physician to

sign the therapy plan of care in the SNF setting. We receive " Eval and Treat "

orders in this setting and in one location have the physician sign the plan of

care or a " clarification order " stating the frequency and interventions. In

another location, they do not do this at all. We are trying to determine if

this is a requlatory requirement or not.

Thank you!

Green, PT

greenk@...

[Guest guest]

Are you asking for Part A residents or Part B? The answer is different dependent

upon the setting you are asking about. For Part A residents, physicians do not

need to sign and date the therapy plan of care as the physician is required to

develop the plan of care for all services the patient requires. Many SNF's have

the physicians sign the therapists plan of care to cover themselves in case the

physician did not do an adequate job of developing the plan of care. Reference

is CMS Pub 100-01, Chapter 4, Section 40-40.6 Here is the link:

http://www.cms.gov/manuals/downloads/ge101c04.pdf

For Part B residents, the physician does need to sign and date the plan of care

developed by the therapist. The reference for this would be CMS Pub 100-02,

Chapter 15, Section 220.1.3 Here is the link to that manual.

http://www.cms.gov/manuals/Downloads/bp102c15.pdf

Rick Gawenda, PT

President

Gawenda Seminars & Consultng, Inc.

www.gawendaseminars.com

Subject: Clarification for SNF Therapy POC's

To: PTManager

Date: Wednesday, September 21, 2011, 1:59 PM

Â

Can anyone provide a reference to the regulation that requires the

Physician to sign the therapy plan of care in the SNF setting. We receive " Eval

and Treat " orders in this setting and in one location have the physician sign

the plan of care or a " clarification order " stating the frequency and

interventions. In another location, they do not do this at all. We are trying

to determine if this is a requlatory requirement or not.

Thank you!

Green, PT

greenk@...

[Guest guest]

Are you asking for Part A residents or Part B? The answer is different dependent

upon the setting you are asking about. For Part A residents, physicians do not

need to sign and date the therapy plan of care as the physician is required to

develop the plan of care for all services the patient requires. Many SNF's have

the physicians sign the therapists plan of care to cover themselves in case the

physician did not do an adequate job of developing the plan of care. Reference

is CMS Pub 100-01, Chapter 4, Section 40-40.6 Here is the link:

http://www.cms.gov/manuals/downloads/ge101c04.pdf

For Part B residents, the physician does need to sign and date the plan of care

developed by the therapist. The reference for this would be CMS Pub 100-02,

Chapter 15, Section 220.1.3 Here is the link to that manual.

http://www.cms.gov/manuals/Downloads/bp102c15.pdf

Rick Gawenda, PT

President

Gawenda Seminars & Consultng, Inc.

www.gawendaseminars.com

Subject: Clarification for SNF Therapy POC's

To: PTManager

Date: Wednesday, September 21, 2011, 1:59 PM

Â

Can anyone provide a reference to the regulation that requires the

Physician to sign the therapy plan of care in the SNF setting. We receive " Eval

and Treat " orders in this setting and in one location have the physician sign

the plan of care or a " clarification order " stating the frequency and

interventions. In another location, they do not do this at all. We are trying

to determine if this is a requlatory requirement or not.

Thank you!

Green, PT

greenk@...

[Guest guest]

*Hello !*

*

*

*You can find this information in the Internet On-Line Manuals at CMS.gov

website. *

*

*

*The answer is found in Manual 100-02, Chapter 8 - " Coverage of Extended

Care " (SNF). Section 40 & 40.1 Provided below from the this link:

http://www.cms.gov/manuals/Downloads/bp102c08.pdf *

*

*

*It also references 100-01 Chapter 4. *

*

*

*

" 40 - Physician Certification and Recertification of Extended Care Services

(Rev. 40, Issued: 11-18-05; Effective: 10-01-05; Implementation: 02-16-06)

Payment for covered posthospital extended care services may be made only if

a physician, nurse practitioner (NP) or clinical nurse specialist (CNS)

makes the required certification, and where services are furnished over a

period of time, the required recertification regarding the services

furnished.

The SNF must obtain and retain the physician’s NP’s, or CNS’s certification

and recertification statements. The intermediary may request them to assist

in determining medical necessity when necessary. The SNF will determine how

to obtain the required certification and recertification statements. There

is no requirement for a specific procedure or form as long as the approach

adopted by the facility permits verification that the certification and

recertification requirement is met. Certification or recertification

statements may be entered on or included in forms, notes, or other records

that a physician, NP or CNS normally signs in caring for a patient, or on a

separate form. Except as otherwise specified, each certification and

recertification is to be signed by a physician, NP, or CNS.

If the SNF’s failure to obtain a certification or recertification is not due

to a question of the necessity for the services, but to the physician’s,

NP’s, or CNS’s refusal to certify on other grounds (e.g., the physician

objects in principle to the concept of certification and recertification),

the SNF cannot charge the beneficiary for covered items or services. Its

provider agreement precludes it from doing so.

If a physician, NP, or CNS refuses to certify, because, in his/her opinion,

the patient does not need skilled care on a continuing basis for a condition

for which he/she was receiving inpatient hospital services, the services are

not covered and the facility can bill the patient directly. The reason for

the refusal to make the certification must be documented in the SNF’s

records.

Certifications must be obtained at the time of admission, or as soon

thereafter as is reasonable and practicable. The routine admission order

established by a physician is not a certification of the necessity for

post-hospital extended care services for purposes of the program. There must

be a separate signed statement indicating that the patient will require on a

daily basis SNF covered care.

In addition, only physicians may certify outpatient physical therapy and

outpatient speech-language pathology services.

40.1 - Who May Sign the Certification or Recertification for Extended Care

Services

(Rev. 40, Issued: 11-18-05; Effective: 10-01-05; Implementation: 02-16-06)

A certification or recertification statement must be signed by the attending

physician or a physician on the staff of the skilled nursing facility who

has knowledge of the case, or by a nurse practitioner (NP) or clinical nurse

specialist (CNS) who does not have a direct or indirect employment

relationship with the facility, but who is working in collaboration with the

physician.

In this context, the definition of a “direct employment relationship” is set

forth in the regulations at 20 CFR 404.1005, 404.1007, and 404.1009. Under

the regulations at 42 CFR 424.20(e)(2)(ii), when an NP or CNS has a direct

employment relationship with an entity other than the facility, and the

employing entity has an agreement with the facility that includes the

provision of general nursing services under the regulations at 42 CFR

409.21, an “indirect employment relationship” exists between the NP or CNS

and the facility. By contrast, such an indirect employment relationship does

not exist if the agreement between the facility and the NP’s or CNS’s

employer solely involves the performance of delegated physician tasks under

the regulations at 42 CFR 483.40(e).

Further information regarding certification and recertification of extended

care services, including details on the content of the certification or

recertification, timing of recertifications and the impact of delays on

certifications and recertifications may be found in Pub. 100-01, Medicare

General Information, Eligibility, and Entitlement Manual, Chapter 4,

“Physician Certification and Recertification of Services,” §§40 - 40.4.6. " "

100-01 Chapter 4 Link You will want to read every paragraph of 40.1 -40.6

It is exact in the expectations, when they must be done and who must do

them.

http://www.cms.gov/manuals/downloads/ge101c04.pdf

Hope this helps!

*

*

*Darlene L. D'Altorio-,PT.,MBA-HCM

Strategist, Rehabilitation Management

CORE Results Group, MediServe

Join Discussions: www.mediserve.com/blog

Office:

Mobile:

Fax :

djones@...

585 N. Juniper Dr., Suite 100 | Chandler, AZ 85226 | 1. |

Optimizing the Value of Patient Care®

Note: The information contained in this message and any attachments is

privileged

and confidential and protected from disclosure. If the reader of this message is

not the intended recipient, or an employee or agent responsible for delivering

this message to the intended recipient, you are hereby notified that any

reading,

dissemination, distribution, copying, or other use of this communication or any

of its attachments is strictly prohibited. If you have received this

communication

in error, please notify the sender immediately by replying to this message and

deleting this message, any attachments, and all copies and backups from your

computer. If you have received this communication in error and are unable to

reply to this message, please notify the sender immediately by contacting

MediServe at .

[Guest guest]

*Hello !*

*

*

*You can find this information in the Internet On-Line Manuals at CMS.gov

website. *

*

*

*The answer is found in Manual 100-02, Chapter 8 - " Coverage of Extended

Care " (SNF). Section 40 & 40.1 Provided below from the this link:

http://www.cms.gov/manuals/Downloads/bp102c08.pdf *

*

*

*It also references 100-01 Chapter 4. *

*

*

*

" 40 - Physician Certification and Recertification of Extended Care Services

(Rev. 40, Issued: 11-18-05; Effective: 10-01-05; Implementation: 02-16-06)

Payment for covered posthospital extended care services may be made only if

a physician, nurse practitioner (NP) or clinical nurse specialist (CNS)

makes the required certification, and where services are furnished over a

period of time, the required recertification regarding the services

furnished.

The SNF must obtain and retain the physician’s NP’s, or CNS’s certification

and recertification statements. The intermediary may request them to assist

in determining medical necessity when necessary. The SNF will determine how

to obtain the required certification and recertification statements. There

is no requirement for a specific procedure or form as long as the approach

adopted by the facility permits verification that the certification and

recertification requirement is met. Certification or recertification

statements may be entered on or included in forms, notes, or other records

that a physician, NP or CNS normally signs in caring for a patient, or on a

separate form. Except as otherwise specified, each certification and

recertification is to be signed by a physician, NP, or CNS.

If the SNF’s failure to obtain a certification or recertification is not due

to a question of the necessity for the services, but to the physician’s,

NP’s, or CNS’s refusal to certify on other grounds (e.g., the physician

objects in principle to the concept of certification and recertification),

the SNF cannot charge the beneficiary for covered items or services. Its

provider agreement precludes it from doing so.

If a physician, NP, or CNS refuses to certify, because, in his/her opinion,

the patient does not need skilled care on a continuing basis for a condition

for which he/she was receiving inpatient hospital services, the services are

not covered and the facility can bill the patient directly. The reason for

the refusal to make the certification must be documented in the SNF’s

records.

Certifications must be obtained at the time of admission, or as soon

thereafter as is reasonable and practicable. The routine admission order

established by a physician is not a certification of the necessity for

post-hospital extended care services for purposes of the program. There must

be a separate signed statement indicating that the patient will require on a

daily basis SNF covered care.

In addition, only physicians may certify outpatient physical therapy and

outpatient speech-language pathology services.

40.1 - Who May Sign the Certification or Recertification for Extended Care

Services

(Rev. 40, Issued: 11-18-05; Effective: 10-01-05; Implementation: 02-16-06)

A certification or recertification statement must be signed by the attending

physician or a physician on the staff of the skilled nursing facility who

has knowledge of the case, or by a nurse practitioner (NP) or clinical nurse

specialist (CNS) who does not have a direct or indirect employment

relationship with the facility, but who is working in collaboration with the

physician.

In this context, the definition of a “direct employment relationship” is set

forth in the regulations at 20 CFR 404.1005, 404.1007, and 404.1009. Under

the regulations at 42 CFR 424.20(e)(2)(ii), when an NP or CNS has a direct

employment relationship with an entity other than the facility, and the

employing entity has an agreement with the facility that includes the

provision of general nursing services under the regulations at 42 CFR

409.21, an “indirect employment relationship” exists between the NP or CNS

and the facility. By contrast, such an indirect employment relationship does

not exist if the agreement between the facility and the NP’s or CNS’s

employer solely involves the performance of delegated physician tasks under

the regulations at 42 CFR 483.40(e).

Further information regarding certification and recertification of extended

care services, including details on the content of the certification or

recertification, timing of recertifications and the impact of delays on

certifications and recertifications may be found in Pub. 100-01, Medicare

General Information, Eligibility, and Entitlement Manual, Chapter 4,

“Physician Certification and Recertification of Services,” §§40 - 40.4.6. " "

100-01 Chapter 4 Link You will want to read every paragraph of 40.1 -40.6

It is exact in the expectations, when they must be done and who must do

them.

http://www.cms.gov/manuals/downloads/ge101c04.pdf

Hope this helps!

*

*

*Darlene L. D'Altorio-,PT.,MBA-HCM

Strategist, Rehabilitation Management

CORE Results Group, MediServe

Join Discussions: www.mediserve.com/blog

Office:

Mobile:

Fax :

djones@...

585 N. Juniper Dr., Suite 100 | Chandler, AZ 85226 | 1. |

Optimizing the Value of Patient Care®

Note: The information contained in this message and any attachments is

privileged

and confidential and protected from disclosure. If the reader of this message is

not the intended recipient, or an employee or agent responsible for delivering

this message to the intended recipient, you are hereby notified that any

reading,

dissemination, distribution, copying, or other use of this communication or any

of its attachments is strictly prohibited. If you have received this

communication

in error, please notify the sender immediately by replying to this message and

deleting this message, any attachments, and all copies and backups from your

computer. If you have received this communication in error and are unable to

reply to this message, please notify the sender immediately by contacting

MediServe at .

[Guest guest]

Hello ,

We are dealing with apples and oranges when we talk SNF regulations. For Part A,

the physician is certifying the need for the extended care services and therapy

is included in that global certification. The requirement of the physician with

regards to therapy is that they review and approve the therapy POT. This can

take many different forms, the most common one being the signing of the POT.

Approval can also be documented in the physician’s own notes, though the

patient care plan if the physician is present (not happening very often), or

through a clarification order that identified the basis of the plan, i.e. the

type of therapy being provided (PT,OT, or SLP) a diagnosis, the frequency and

duration and the therapy LTGs.

Under Part B the regulations are that the physician review and approve the plan

and by doing so also certifies need for that therapy service. The same

regulations apply for review and approval as under Part A, that is the physician

can sign the plan, always the best, or any other method that clearly shows they

have approved the plan.

The guidelines for both can be found in the IOM Pub.100-2, Benefits Manual at

http://www.cms.gov/Manuals/IOM/list.asp The requirements for Part A are found

in Chapter 8, section 40, Physician Certification and Recertification of

Extended Care and the requirements for Part B in Chapter 15, 220.1.3 –

Certification and Recertification of Need of Treatment and Therapy Plans of

Care.

Under Part B, in that section it states “Certification requires a dated

signature on the plan of care or some other document that indicates approval of

the plan of care.†For Part A, the requirement for signed POT was rescinded in

the Federal Register / Vol. 69 No. 146 / Friday July 30 2004. Page 45780.

As always, the preference is for the physician to actually sign the POT, but for

those who may be tardy in this requirement, alternatives are made available as

long as the facility can identify that the POT was sent and the physician has

made no disagreement to the plan.

Also, you need to look at what directives your Practice Act may have as they may

be more stringent than Medicare.

I hope this helps,

ine

ine M. o, PT

Owner

Encompass Consulting & Education, LLC

8114 NW 100th Terrace, Tamarac, FL 33321-1259

We work hard to make sure you are " getting it right from the start " . Visit our

website at <http://www.encompassmedicare.com/> www.encompassmedicare.com and

see what we can do for you. While there sign up for our free e-mail Newsletter

" Medicare News and Rules for Therapists " .

We specialize in consulting services, seminars and customized education services

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NOTICE: This communication is intended only for the use of the individual or

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From: cchcrehabmgr <kjgpt@... <mailto:kjgpt%40sbcglobal.net> >

Subject: Clarification for SNF Therapy POC's

To: PTManager <mailto:PTManager%40yahoogroups.com>

Date: Wednesday, September 21, 2011, 1:59 PM

Can anyone provide a reference to the regulation that requires the Physician to

sign the therapy plan of care in the SNF setting. We receive " Eval and Treat "

orders in this setting and in one location have the physician sign the plan of

care or a " clarification order " stating the frequency and interventions. In

another location, they do not do this at all. We are trying to determine if this

is a requlatory requirement or not.

Thank you!

Green, PT

greenk@... <mailto:greenk%40ccf.org>