Is Your Practice Ready for a Medicare Audit? | Part Five

Physical Therapy Documentation_Audit-Checklist

In this fifth in our series of Blogs asking the question, “Is your practice ready for a Medicare audit?” we discuss Certifications and Re-certifications of the Plan of Care.

Medicare requires that a Plan of Care be prepared by a therapist or other qualified professional, who must sign and date the document.  Additionally, the Plan of Care must be certified by a physician/NPP.  The certification of the Plan of Care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment.

The Plan of Care should be certified as soon as it is established.  Medicare may deny payment if the Plan of Care is not certified.  Failure to obtain this required certification is among the most common findings in CERT audits performed by Medicare.

Re-certification of the Plan of Care also requires a physician or non-physician signature and date, and it should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification.

A certification is different from an order or referral in that it must contain all required elements of a Plan of Care.  Certification requires a dated physician/NPP signature on the therapy Plan of Care or some other document that indicates approval of the Plan of Care.  Certifications/re-certifications should include the following elements:

  • The date from which the Plan of Care being sent for certification becomes effective (for initial certifications, the initial evaluation date will be assumed to be the start date of the certified Plan of Care.)
  • Diagnoses.
  • Long term treatment goals.
  • Type, amount, duration and frequency of therapy services.
  • Signature, date and professional identity of the therapist who established the Plan.
  • Dated physician/NPP signature indicating that the therapy service is or was in progress and the physician/NPP makes no record of disagreement with the Plan.

The interval length shall be determined by, “the patient’s needs, not to exceed 90 days”  Certifications which include all the required Plan of Care elements will be considered valid for the longest duration in the plan (such as 3x/wk for 6 weeks which will be considered as a total of 18 treatments).  If treatment continues past the longest duration specified, a recertification will be required.

Delayed Certification:  Medicare provides for Delayed Certification when a physician/NPP makes a certification accompanied by a reason for the delay.  This explanation should be kept as a part of the medical record.  This allows needed therapy to be provided even if certification of the plan is delayed.

Note:  Genco recently assisted a client in responding to a Medicare Audit where claims for any treatments provided in a period where there was no Certified Plan of Care were denied.

Medicare requires a legible signature of the person(s) who provided the service and certifying the Plan of Care. Signatures may be hand written or electronic. Electronic or hand written signatures that have been communicated through facsimile are also acceptable. Effective April 28, 2008, stamp signatures were no longer acceptable.

In our next Blog we will discuss documenting the care provided.

Genco Healthcare helps practices achieve and maintain a culture of compliance.  We also assist Healthcare Attorneys in defending their clients who have been audited or subject to pre-payment review.  Consequently, we have our finger on the pulse of precisely what Medicare’s expectations are when it comes to medical documentation.  Contact us by email: