Medicare POC

It seems like there have been a lot of post-payment Medicare reviews this past year.  Unfortunately, with these reviews there has been take-back of payments due to improper documentation.  The most frequent errors in post-payment reviews seem to be related to the Plan of Care (POC) so let’s review the requirements for your POC and make sure you are 100% compliant.

The POC must contain at a minimum

  • Diagnosis
  • Long-term treatment goals
  • Type of treatment
  • Amount, duration, and frequency of therapy services
  • Medical necessity
  • Date and Signature with credentials of person establishing the POC
  • It must be written

The POC must be established by a physician, non-physician provider, physical therapist, occupational therapist, or speech-language pathologist. Chiropractors and Dentists may not refer patient to therapy services or certify therapy plans of care for Medicare.

If the POC is established by the PT, OT, or SLP, it must be forwarded to the physician or non-physician provider, signed by them and returned to the clinic.  It is not necessary to have that signature prior to commencing treatment but you must have proof of your submitting the POC and attempts to get the signed copy returned.

Error #1:  Prescriptions and Referrals that patients bring to the clinic on their initial evaluation rarely have all of the required information to pass as a POC and therefore cannot be used as a POC.  The most frequently missing information in the prescription/referral is long term treatment goals and duration and frequency of therapy services.

Error#2:  Treatment may not commence until the POC has been written.  A patient coming via direct access or with a prescription/referral lacking all of the necessary information, must have evidence that a POC was written, signed by the provider establishing the POC, and dated on the date that treatment was initiated.  Without that proof, only the evaluation will be re-imbursed.  Treatment codes will be denied.

Error#3:  POCs are not being returned to the clinics and there is no proof of attempts to obtain the signed POC from the physician/non-physician provider’s office.  Therefore, it is being treated as no POC being established and treatment will only be re-imbursed on the initial date of service when the POC was written.

Error#4: Not following the frequency and duration written in the POC.  This can be a gray area and seems to be a little dependent on the MAC doing the review.  The clearcut part of this is that if you state a duration of 4 weeks in your POC and continue treating the patient beyond that without an updated POC you will be in violation.  The CMS manual acknowledges that it may be appropriate to taper the therapy based on therapist’s clinical judgement. Their recommended documentation is to state “3 times a week tapered to once a week over 6 weeks”.  In the reviews I have seen, this can be interpreted as 18 visits or 6 weeks, whichever comes first.  If you exceed the 18 visits or the 6 weeks, the excess visits will be denied.  Don’t be fooled by the requirement that a POC is only required every 90 days.  That is only if the POC you wrote has a written duration of 90 days.  If you have written the POC for less than 90 days, you need to update it at its termination.  Also remember that a POC is different than the Progress Note that is required every 10 visits.  The Progress Note is not required to be sent to or signed by the physician/non-physician provider but must be in the therapy medical record.

Systems4PT provides the tools to keep you compliant.  With Systems4PT there is no need for spreadsheets and lists to determine who needs a POC or whose POC is missing.  It is all automated for you with reminders and HardStop Medicare Compliance.

Information Sources:

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