Outpatient Physical Therapy Continuation Request Requirements

Clinical Documentation Requirements

Treatment Plan/Plan of Care Requirements

All therapy should be provided in accordance with an ongoing, written treatment plan/plan of care. The treatment plan should be/include all of the following:

• Established by a physician, Non-Physician Practitioner (NPP), or a qualified therapist providing such services
• Reviewed periodically by a Physician/NPP Provider: The plan of care must be recertified and signed, documenting the need for continued or modified therapy whenever a significant modification becomes evident or at least every 90 days after treatment starts
• Include a completed Notice of Advice form or referring Practitioner: A physical therapist may treat a patient without a referral for up to 10 visits or 30 days, whichever comes first, and must have the patient complete a Notice of Advice form. After this, the patient must be referred to a referring practitioner for evaluation

Establishing Medical Necessity

The purpose of the written treatment plan/plan of care is to assist in determining medical necessity and should include the following:

• The diagnosis and date of onset or exacerbation of the disorder/diagnosis
• A reasonable estimate of when the goals will be reached
• Long-term and short-term goals that are specific, quantitative and objective
• The frequency and duration of treatment
• The specific treatment techniques and/or exercises to be used in treatment
• Signatures of the patient's attending physician and physical therapist

Continuing Authorization Requirements

The Plan Of Care should be ongoing, (i.e., updated as the patient's condition changes), and treatment should demonstrate reasonable expectation of improvement (as defined below):

• All therapy services are considered medically necessary only if there is a reasonable expectation that physical therapy will achieve measurable improvement in the patient's condition in a reasonable and predictable period of time
• The patient should be reevaluated regularly (at least monthly), and there should be documentation of progress made toward the goals of physical therapy
• The treatment goals and subsequent documentation of treatment results should specifically demonstrate that physical therapy services are contributing to such improvement

Additional Resources

• Frequently Asked Questions for Physical Therapy
• Medicare Benefit Policy Manual: Chapter 15 – Covered Medical and Other Health Services
• Outpatient Rehabilitation Therapy Services: Complying with Documentation Requirements
• Provision of Physical Therapy Services

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm