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Certification of therapy plan of care for bedded outpatients

21 Feb 2016

By: Susan Redmond, OT/L, MBA, manager of acute therapies

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CMS requires physician certification on the "therapy plan of care" for outpatients with Medicare B coverage (this includes our in-house observation status patients). This requirement is only for those patients who are seen for treatment, not for evaluation only. This doesn’t happen frequently, but those patients who are not able to quickly discharge (from observation status) often have functional limitations.

On Feb. 1, the Acute Therapy Department began identifying these cases and will place an order that must then be co-signed by the referring physician. The order will consist of the following:

“(Occupational Therapy, Physical Therapy, or Speech-Language Pathology)

I have reviewed the therapy evaluation and plan of care. I certify the stated services are needed during hospitalization and advise to continue with current treatment plan.“

If there is more than one discipline (PT, OT, ST) treating the patient, there will be multiple orders requiring co-signature. The goals are located in the ‘care plan’ section of Epic. The therapy interventions, frequency, and evaluation findings can be found in the ‘notes’ section. If you have questions about the plan or the goals, feel free to reach out to the therapist.

If you have questions about the requirement or the process, please contact Susan Redmond, acute therapies manager, at