When to Use a Progress Report vs. a Plan of Care When Treating Medicare Patients

By: Jennifer Heiligman, PT, MPT

We all know Medicare likes to keep us on our toes in terms of outpatient rehab therapy documentation requirements.  In addition, those requirements are not always communicated in the clearest manner possible.  Take for instance, the question “Do I need a Progress Report or a Plan of Care?”  Below we have summarized the information that will hopefully make the answer to that question much clearer.

Plan of Care

When treating Medicare patients, the Plan of Care refers to the written treatment plan for which the intended therapy services must specifically relate to.  The Plan of Care is established at the time of the first visit with the patient and is derived from the clinical information gathered during the Initial Therapy Evaluation.

Per Medicare, the minimal information required in the Plan of Care is as follows:

  • Diagnosis
  • Long-term treatment goals
  • Type of rehab therapy services (PT, OT, or SLP) 
  • Amount of therapy (number of treatment sessions in a day)
  • Frequency of therapy (number of treatment sessions in a week)
  • Duration of therapy (total number of weeks)

Once this Plan of Care (POC) is signed and dated by the therapist who established it, the plan should be sent to the physician to be certified.  If the physician agrees with the plan, the physician must sign and date the POC within 30 days of the initial visit in order to comply with Medicare regulations.  The POC is then certified for the duration of time that was initially established or 90 calendar days, whichever is shorter. Compliantly speaking, the duration should mirror the time frame for the longest functional goal in days, but must not exceed 90 calendar days.

The Medicare POC will need to be recertified at least every 90 days or sooner if the duration of the initial POC was less than 90 days or if a significant modification to the plan is needed.  A modification may be necessary when there is a significant change in a long term goal, for example if a new condition is added to the treatment plan.  If a recertification is required and the physician agrees, their signature and date are required within 30 calendar days of the creation of the new POC, just like for the certification of the initial POC.

What happens if the physician does not certify the Medicare POC within 30 calendar days?  Medicare does allow for delayed certifications when certain criteria are met.  For example, Medicare will consider the certification requirement met when the physician signs a POC at any later date when accompanied by an explanation for the delay.  In addition, certifications are acceptable without justification when received 30 days after the original due date.  It is always a good idea on the part of the therapist to keep a record of any attempts or communication with the physician’s office that occurred while trying to obtain a POC certification.  This may need to be submitted as supporting documentation should Medicare question the status of the POC certification. 

Progress Reports

A Progress Report provides justification for the medical necessity of the skilled therapy being provided to the patient.

Per Medicare, a Progress Report should include:

  •  Objective evidence to support the need for skilled treatment  
    • This includes such things as validated functional outcome measures and standardized patient assessment tools.  These can help to quantify progress when used at the beginning of treatment and repeated throughout the episode of care.
  • Assessment of progress toward each goal
  • Plan for continuing treatment, including recommended frequency and duration
  • Changes to long term goals (if applicable)

Medicare requires a Progress Report be completed at least every 10 treatment days.  The next reporting period begins on the next treatment day after the Progress Report was performed.  It is important to know that the dates for recertification of a Medicare POC do not affect the dates of a required Progress Report.  Those time frames are independent of each other.  In addition, a Progress Report does not, in most cases, require a physician signature.  You should verify any additional state specific requirements by reviewing your state practice act.  

The Medicare POC and the Progress Report may collide if, after completing your Progress Report, you use your clinical judgement to determine that a significant change in the previously established treatment plan is necessary.  A significant change would include such things as an addition of a new condition to the treatment plan or a necessary change in the long term goals.  When that situation occurs, you must create a new POC to be sent to the physician to be certified.  The start date of the new POC would be the date the progress report was performed.  The end date, as with any other Medicare POC, should be the duration set for the longest functional goal in days or 90 calendar days, whichever is less.  When recertifying a Medicare POC, the physician has the same requirement of 30 calendar days to sign and date the POC.

Staying Compliant with Time Frames

Since Medicare could potentially deny or claw back payment if the above time frames are not met, it is essential that your practice establish a workflow to keep track of Medicare POCs and Progress Reports.  If your EMR does not offer a tracking system, then this may end up being a manual process using home grown spreadsheets or some other recording method.  However, if you are an OptimisPT user, you can take advantage of the embedded alerts, reminders and reports that can track this for you.  

Within OptimisPT, there is an alert that will display when you get 7 days prior to the Medicare POC expiration date.  This alert can be seen along the left hand side of the patient’s visit and within the patient’s episode of care chart.  When the Medicare POC is returned signed and dated by the physician, the POC should be marked as “certified” within OptimisPT.  This can be done in the patient’s Initial Visit or within the patient’s episode of care chart.  You can run the Medicare Certification Status Report to verify which POCs have been certified and which have yet to be certified.  This is a great tool to stay within the 30 day period required by Medicare for the physician to sign the POC.  

In regards to Progress Reports, there is an alert on the left hand side of the patient’s visit indicating how many visits it has been since the last progress report.  This alert will count up and when it gets to 7 visits it turns yellow and when it reaches 10 visits it turns red.  The color change is helpful in catching the attention of the therapist.   The Progress Report alert is also visible on the appointment block and can be seen when the patient is checked in on the schedule.  This adds an additional stop gap to prevent missing the 10 visit time frame.  If the front office staff sees a progress report is due they can update the visit type to “Progress Report” which will help to alert the therapist.

This article is designed to provide relevant and useful information to be applied when treating and documenting for your Medicare patient population.  Staying compliant with Medicare documentation requirements can seem like a daunting task.  However, with the right partner, it does not need to be so difficult.  OptimisPT continuously updates our EMR system to represent any changes in regulations.  We include embedded alerts, reminders, and reports to assist our users in maintaining the highest level of compliance. 

If you are a current OptimisPT user and have questions regarding any of the features or information discussed, please contact support.  If you are not a current OptimisPT user and would like to schedule a demo to see these features in real time, click here.


Outpatient Rehabilitation Therapy Services:  Complying with Documentation Requirements

Medicare Benefit Policy Manual Chapter 15