Provider Enrollment and Ongoing Responsibilities : Documentation

Plan of Care

PT, OT, and SLP providers are required to establish a written POC for all members before providing services. The POC must be promptly signed and dated by the prescribing physician and included in the member's medical record. The POC must include the following:

• Diagnoses
• Amount, frequency, duration, and specific PT, OT, or SLP services
• Reports of current status that support the POC
• Measurable objectives
• Anticipated short-term and long-term functional goals, which must be outcome based, appropriate for the diagnoses or presenting problems, and related to the specific PT, OT, and SLP services
• A reasonable estimate of when the goals will be achieved
• Communication and coordination with other providers, including such documentation as the following:
• Date(s) of communication
• Person(s) contacted
• A brief summary of the PT, OT, and SLP services provided by the other providers
• The unique and specific contribution of this PT, OT, or SLP provider given other PT, OT, and SLP providers' contributions

At least every 90 days, or earlier if necessary, both of the following must occur:

• Physical therapy, OT, and SLP providers are required to do one of the following:
  • Develop a new POC
  • Review and update the POC
• Physicians are required to sign and date the POC with each review.

Physician Review and Signature on Successive Plans of Care

All successive POC must be reduced to writing by the therapist and reviewed, signed, and dated by the prescribing physician at least every 90 days. The physician's signature and date on successive POC becomes the therapist's written order, and must be obtained prior to providing ongoing treatment. Should the severity of the member's condition require revision of the POC more frequently than every 90 days, the providing therapist is required to review and develop a new POC as frequently as the severity of the member's condition requires. Wisconsin Medicaid may deny or recoup reimbursement for services provided without a physician prescription or before a POC is established.