Physical therapy services guidelines updated

We’ve updated the medical record documentation requirements for physical therapy services. The updates include:

Expiration of physician orders
Unless the ordering physician specifies an earlier date, orders expire after 90 days, even those marked "ongoing" or indicating a period of time longer than 90 days. In all cases, after 90 days, a recertification order (signed and dated by the physician) must be obtained. The date of the first treatment is the start of the 90-day period.

Previously, physician orders expired after 30 days.

For verbal orders, the request for physician signature and date must be initiated within 10 days of receipt of the verbal order, and obtained within 30 days. Previously, the physician signature and date had to be obtained within 10 days of the verbal order.

Treatment plan
Physical therapists must submit treatment plans to physicians for approval and signature. Physician certification of the plan (by signature or verbal order) must be dated within 30 days of the first day of treatment (including evaluation) and documented in the patient medical record. Payment may be denied if physician certification is not obtained.

Discharge summary
Physical therapists must write a discharge summary when their services end. The summary must contain details about the response to treatment, achievement or lack of achievement of goals, and any related recommendations for follow-up or self care.

For more information, see the “Documentation Guidelines for Physicians and Other Professional Providers” chapter of your online provider manual. To view the chapter:

• From web-DENIS, click on BCBSM Provider Publications and Resources.
• Click on Provider Manual.
• Click on Provider Type and select yours from the “Make Selection” box.
• Click on the Search button and then on the “Documentation Guidelines for Physicians and Other Professional Providers” chapter.