CMS Pub. 100-02, ch. 15, § 220.1.2

Therapy, or Speech-Language Pathology Services

(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)

Reference: 42CFR 410.61 and 410.105(c) (for CORFs)

A. Establishing the plan (See §220.1.3 for certifying the plan.)

The services must relate directly and specifically to a written treatment plan as described

in this chapter. The plan, (also known as a plan of care or plan of treatment) must be

established before treatment is begun. The plan is established when it is developed (e.g.,

written or dictated).

The signature and professional identity (e.g., MD, OTR/L) of the person who established

the plan, and the date it was established must be recorded with the plan. Establishing the

plan, which is described below, is not the same as certifying the plan, which is described

in §§220.1.1 and 220.1.3

Outpatient therapy services shall be furnished under a plan established by:

• A physician/NPP (consultation with the treating physical therapist,

occupational therapist, or speech-language pathologist is recommended.

Only a physician may establish a plan of care in a CORF;

• The physical therapist who will provide the physical therapy services;

• The occupational therapist who will provide the occupational therapy

services; or

• The speech-language pathologist who will provide the speech-language

pathology services.

The plan may be entered into the patient’s therapy record either by the person who

established the plan or by the provider’s or supplier’s staff when they make a written

record of that person’s oral orders before treatment is begun.

Treatment under a Plan. The evaluation and treatment may occur and are both billable

either on the same day or at subsequent visits. It is appropriate that treatment begins

when a plan is established.

Therapy may be initiated by qualified professionals or qualified personnel based on a

dictated plan. Treatment may begin before the plan is committed to writing only if the

treatment is performed or supervised by the same clinician who establishes the plan.

Payment for services provided before a plan is established may be denied.

Two Plans. It is acceptable to treat under two separate plans of care when different

physician’s/NPP’s refer a patient for different conditions. It is also acceptable to

combine the plans of care into one plan covering both conditions if one or the other

referring physician/NPP is willing to certify the plan for both conditions. The treatment

notes continue to require timed code treatment minutes and total treatment time and need

not be separated by plan. Progress reports should be combined if it is possible to make

clear that the goals for each plan are addressed. Separate progress reports referencing

each plan of care may also be written, at the discretion of the treating clinician, or at the

request of the certifying physician/NPP, but shall not be required by contractors.

B. Contents of Plan (See §220.1.3 for certifying the plan.)

The plan of care shall contain, at minimum, the following information as required by

regulation (42CFR424.24, 410.61, and 410.105(c) (for CORFs)). (See §220.3 for further

documentation requirements):

• 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

each discipline separately. For example, a physical therapist may not provide services

under an occupational therapist plan of care. However, both may be treating the patient

for the same condition at different times in the same day for goals consistent with their

own scope of practice.

The amount of treatment refers to the number of times in a day the type of treatment will

be provided. Where amount is not specified, one treatment session a day is assumed.

The frequency refers to the number of times in a week the type of treatment is provided.

Where frequency is not specified, one treatment is assumed. If a scheduled holiday

occurs on a treatment day that is part of the plan, it is appropriate to omit that treatment

day unless the clinician who is responsible for writing progress reports determines that a

brief, temporary pause in the delivery of therapy services would adversely affect the

patient’s condition.

The duration is the number of weeks, or the number of treatment sessions, for THIS

PLAN of care. If the episode of care is anticipated to extend beyond the 90 calendar day

limit for certification of a plan, it is desirable, although not required, that the clinician

also estimate the duration of the entire episode of care in this setting.

The frequency or duration of the treatment may not be used alone to determine medical

necessity, but they should be considered with other factors such as condition, progress,

and treatment type to provide the most effective and efficient means to achieve the

patients’ goals. For example, it may be clinically appropriate, medically necessary, most

efficient and effective to provide short term intensive treatment or longer term and less

frequent treatment depending on the individuals’ needs.

It may be appropriate for therapists to taper the frequency of visits as the patient

progresses toward an independent or caregiver assisted self-management program with

the intent of improving outcomes and limiting treatment time. For example, treatment

may be provided 3 times a week for 2 weeks, then 2 times a week for the next 2 weeks,

then once a week for the last 2 weeks. Depending on the individual’s condition, such

treatment may result in better outcomes, or may result in earlier discharge than routine

treatment 3 times a week for 4 weeks. When tapered frequency is planned, the exact

number of treatments per frequency level is not required to be projected in the plan,

because the changes should be made based on assessment of daily progress. Instead, the

beginning and end frequencies shall be planned. For example, amount, frequency and

duration may be documented as “once daily, 3 times a week tapered to once a week over

6 weeks”. Changes to the frequency may be made based on the clinicians clinical

judgment and do not require recertification of the plan unless requested by the

physician/NPP. The clinician should consider any comorbidities, tissue healing, the

ability of the patient and/or caregiver to do more independent self-management as

treatment progresses, and any other factors related to frequency and duration of

treatment.

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

physician’s/NPP’s signature required on the change, (long term goal changes may be

accompanied by changes to procedures and modalities).