A Plan of Care (POC) is a written treatment plan outlining a patient's rehabilitation therapy. It serves as a roadmap for treatment, ensuring therapy services are medically necessary, goal-oriented, and properly structured.
The referring physician needs to return the certified (signed and dated) POC within 30 days from the first day of treatment, including evaluation. If after 30 days the POC has not been returned, you need to demonstrate reasonable efforts to obtain it. PatientStudio's built-in e-fax makes it easy to fax your plan of care and document your attempts at certification.
Recertification is required every 90 days or before the initial POC expires, whichever comes first.
The following information is taken directly from MLN fact sheet Complying with Outpatient Rehabilitation Therapy MLN Fact Sheet: Documentation Requirements.
Written Plan of Care (POC) Requirements
Outpatient rehabilitation therapy services must follow a written Plan of Care (POC) before treatment begins. The POC can be created by a physician, physical therapist (PT), occupational therapist (OT), speech-language pathologist (SLP), or a non-physician practitioner (NPP). However, only a physician can establish a POC in a Comprehensive Outpatient Rehabilitation Facility (CORF).
Key POC Components:
Diagnosis: Medical condition requiring therapy
Long-term Treatment Goals: Expected patient outcomes
Therapy Services: Specifying PT, OT, or SLP
Session Details:
Type: Specific treatments or interventions
Amount: Number of sessions per day
Frequency: Sessions per week
Duration: Total weeks or sessions planned
The POC must be signed and dated by the provider who established it. Any significant modifications, such as changes in goals or treatment due to a new condition, require physician or NPP approval.
Initial POC Certification
To ensure compliance, a physician or NPP must certify the POC within 30 days of the first treatment date including the evaluation. Certification is valid when:
The POC is signed and dated by a physician or NPP.
The initial evaluation supports the need for treatment.
Recertification
Recertification is required every 90 days or when significant modifications are made to the POC. If treatment extends beyond the initial certification period, a provider must:
Physician signs and dates the recertification, documenting the need for continued or adjusted therapy.
Complete recertification earlier if the treatment plan duration is less than 90 days.
Plan of Care in PatientStudio
Medicare providers will need to understand how to send, manage and track plan of care certification.
How to Create a Plan of Care in PatientStudio
How to Create a Plan of Care in PatientStudio
From the Evaluation a therapist can create a new plan on care (POC).
From a progress note or daily note the therapists can edit the plan of care.
1. Add Primary Provider
2. Select Discipline (PT, OT, SLP)
3. Add a primary diagnosis code
4. Click add all treatment you plan on performing as part of this plan of care.
Note: This is separate from the treatments/interventions you perform as part of the evaluation. The POC treatments should encompass all treatments that will be provided over the entire duration of this POC.
5. Select Duration
6. Select Frequency
7. Add short and long term goals
8. Set Progress Note Alert
How to Send the Plan of Care
How to Send the Plan of Care
Following the completion of a note, the therapist can send the POC via email or eFax.
1. Submit the note or eval.
2. Click the "Recipient" field.
3. Select the "Referring Provider"
4. Click Send via eFax
5. Add a Subject
6. Select cover letter option
7. Click "Sign & Submit"
How to Send the Plan of Care via the Patient Profile
How to Send the Plan of Care via the Patient Profile
Alternatively, a user can send the POC to a referring provider via the patient profile and the documents tab.
1. Click "Documents"
2. Click "Send Records"
3. Click this checkbox.
4. Select Recipient
5. Click referring provider
6. Click "Send via E-fax"
7. Add "Subject"
8. Add a "Note"
9. Select cover letter option
10. Click "Send"
11. Click "Ok"
How to upload a signed (certified) Plan of Care to PatientStudio
How to upload a signed (certified) Plan of Care to PatientStudio
Once the signed/certified POC has been returned the user will need to upload the POC in order to change the POC status.
1. Click "Documents"
2. Click "Send Records"
3. Click this checkbox.
4. Select Recipient
5. Click referring provider
6. Click "Send via E-fax"
7. Add "Subject"
8. Add a "Note"
9. Select cover letter option
10. Click "Send"
11. Click "Ok"
Plan of Care and Certification Statuses
Plan of Care and Certification Statuses
POC Statuses:
Active - Most current POC for this case / condition
Inactive - A newer POC has replaced this one
Certification Statuses:
No Signature Required - This payer and/or POC does not require certification
Signature Required - POC has been established and is awaiting physician signature/certification
Signed - Signed/certified POC has been received.
Certification Tracking & Reporting
Certification Tracking & Reporting
1. Click "Reports"
2. Click "Care Plans"
3. Optionally sort by "Certification Due Date"
4. Select "Sort by"
