Creating a Plan of Care in Physical Therapy

“A Plan of Care is defined as a personalized treatment strategy that sets measurable goals and ensures that all stakeholders in healthcare remain aligned throughout the therapy process.” 

A well-structured Plan of Care (POC) in physical therapy is important for guiding patients toward a successful recovery. It is reported that 68% - 72% of patients experience significant improvement in their condition following a solid POC. 

With that in mind, let’s explore how to establish a Plan of Care, as well as the common challenges and solutions to ensure its success.

Understanding the Plan of Care in Physical Therapy

A plan of care, or treatment plan, is customized and created by a physical or occupational therapist to provide a clear strategy addressing a patient’s unique health needs and treatment goals. This plan specifies the interventions, exercises, and techniques that will be implemented to enhance the patient’s condition. 

So, what should you consider to add in your plan of care? The plan of care should contain the following core components in Physical Therapy:

• Diagnoses: A clear identification of the patient’s condition to guide treatment.
• Long-Term Goals: Objectives should be set for the entire course of care, not just for a single interval or phase, ensuring complete planning.
• Type of Treatment: This specifies the type of therapy, such as physical, occupational, or speech therapy, or a detailed description of a particular intervention. For plans established by a physician or non-physician practitioner (NPP), the specific type of therapy must be clearly outlined.
• Amount: Refers to how many times per day the treatment will be administered. If unspecified, it is generally assumed to be one session per day.
• Duration: Indicates the total time frame of the plan, considering the 8-minute rule, expressed in weeks or total sessions.
• Frequency: Describes how often the treatment will be provided each week. In cases where this is not stated, a default assumption of one session per week is applied.

Although understanding a plan of care is essential, it is equally important to establish a plan for your patients, ensuring that interventions are targeted, effective, and matched to their specific needs.

How to Establish a Plan of Care in Physical Therapy?

When establishing a plan of care, it is important to ensure it is created by a qualified professional, such as a qualified physical therapist. Also, the plan of care must be finalized before any therapy treatments can begin, ensuring a structured and compliant approach to patient care.

Here are some of the points to remember when writing a plan of care:

• Ensure the plan includes your signature, professional credentials (e.g., PT, OT), and the date it was established.
• Obtain and document certification (and recertification, if needed) with a physician or non-physician practitioner’s signature and date.
• Record any changes to the plan of care, including what was modified and why previous goals were not met.
• Track when the plan of care is sent for physician/non-physician practitioner approval and when it is returned with the proper signature and date. 
• Follow up promptly on any unreturned plans.

A certified plan of care ensures compliance and effective treatment in your services. When it comes to Medicare patients, certification is an official validation, not just a course. Requiring a physician’s or NPP’s signature to confirm medical necessity. Let’s understand this better.

PT Plan of Care Certification Requirements

If you're treating Medicare patients, you must understand how to navigate Medicare's certification and re-certification requirements for plans of care. The following are the requirements that must be met:

1. Necessity for Physical Therapist or Non-Physician Provider (NPP) Certification

While the physical therapist personalizes and writes the POC, it must be reviewed and certified by a physician or NPP to ensure compliance and approval for treatment.

The physician or NPP must provide a signature, which can be either electronic or handwritten but not a stamp, to validate the plan. Medicare does not require the certifying physician to have personally seen the patient; however, some physicians may have policies that mandate a patient visit prior to certification.

2. Timing of Certification

Certification should occur within 30 days of the patient’s initial therapy treatment to ensure compliance and avoid delays. The signed and dated Plan of Care authorizes the physical therapist to proceed with treatment as outlined in the plan. 

Furthermore, if the physician or NPP provides verbal certification, then it must be followed-up with a signed document within 14 days of giving the verbal approval.

3. Recertification Requirements

Although the certification remains valid until the treatment duration specified in the plan ends, the patient’s condition changes significantly (necessitating a revision of goals) or 90 days after the initial treatment—whichever comes first. If further care is needed beyond this point, a new Plan of Care must be submitted for recertification, following the same process.

4. Delayed Certification Requirements

Delayed certification is permitted if a physician or NPP provides the required certification at a later date. To satisfy delayed certification requirements:

1. Single Document Certification: Submit one or more certifications or recertifications consolidated into a single, signed, and dated document.
2. Reason for Delay: Include a clear explanation for the delay, such as a physician not signing on time or the original certification being misplaced.
3. Long Delays (Over 6 Months): For delays exceeding 6 months, include additional documentation to demonstrate the need for care and confirm the patient was under the care of a physician during the treatment period. Examples of supporting documents include:
   
   • Physician orders
   • Progress notes
   • Records of telephone contact
   • Requests for certification
   • A signed statement from the physician or NPP

Once the Plan of Care is certified by an NPP, you can proceed with developing and implementing the treatment plan while ensuring it aligns with the established goals. This includes carrying out the prescribed interventions and tracking patient progress to ensure effective outcomes. 

Implementing the Plan of Care in Physical Therapy

Implementing a Plan of Care in physical therapy is a systematic process that requires continuous assessment and modification to ensure optimal outcomes. Let’s take a look below at how, as a Physical therapist, you must remain flexible and responsive to patient needs.

1. Initial Implementation of the First Therapy Visit After Evaluation

During the first therapy visit, you must conduct an examination and evaluation to establish a diagnosis and prognosis before beginning treatment. The evaluation focuses on identifying risk factors, cognitive or environmental barriers, and opportunities for health promotion.

During the visit, you will evaluate the following:

• Documents and dates of the examination results
• Identifies the patient’s physical therapy and other relevant health needs
• Performs or orders appropriate diagnostic and physiological tests or measures
• Gathers sufficient data to establish a diagnosis, prognosis, and Plan of Care (POC).
• Refers the patient to other services if needed
• Incorporates, when available, results from prior diagnostic tests into the evaluation
  

2. Adapting Plans Based on Progress and Changes in Therapy Needs

According to the Standards of Practice for Physical Therapy by the American Physical Therapy Association (APTA), adapting the Plan of Care based on patient progress and evolving therapy needs is an integral responsibility of physical therapists. This process ensures that treatment remains patient-centered and outcome-driven.

Modifications to the POC may include:

• Updating goals to reflect achieved milestones or new priorities
• Altering interventions to better address changes in the patient’s condition or response to therapy
• Revising the anticipated timeline for discharge based on progress.

‍

You might like reading about Understanding and complying with the change in policy implemented on Jan. 1, 2025, under the 2025 fee schedule.

The plan of care can provide a clear direction throughout the treatment process, but establishing one may pose some challenges. 

What Are the Main Challenges in Completing a POC and Their Solutions?

As a physical therapist, you face various challenges when managing Plans of Care. Here’s a clear breakdown of challenges and solutions to address them effectively:

‍

Challenge 1: Incomplete or Missing Documentation

You may encounter issues where certifications, progress notes, or evaluations are incomplete or missing, which can lead to claim denials.
Solution: Ensure all documentation is thorough and accurate. Use standardized templates to streamline record-keeping and minimize the risk of omissions.

‍

Challenge 2: Lack of Specificity in Treatment Plans

Plan of Care documents that lack detailed information about diagnoses, goals, or treatment specifics may fail to meet compliance requirements.
Solution: Create detailed POCs that clearly outline diagnoses, measurable goals, and the type, amount, frequency, and duration of therapy. Practice management tools like 

Spry PT can simplify the process and ensure compliance.

‍

Challenge 3: Delayed Certifications and Recertifications

Delays in obtaining certifications from physicians or NPPs can disrupt patient care and reimbursement.
Solution: Use a tracking system to monitor certification timelines and send timely reminders. Automate alerts for upcoming deadlines to avoid delays.

‍

Challenge 4: Failure to Update Plans of Care

Significant changes in a patient’s condition may require updates to their POC, and failing to document these changes can lead to compliance issues and penalties.
Solution: Regularly review and update POCs as needed. Use software solutions to flag when updates are required, ensuring patient care aligns with their evolving needs.

‍

Challenge 5: Patient Non-Compliance with Plan of Care

Patients not adhering to their treatment plans can hinder progress and outcomes.

Solution: Foster better adherence by clearly communicating treatment plans and setting realistic expectations. Educate patients on the importance of following their plans and provide reminders for home exercise programs and appointments using patient engagement tools. Build strong relationships with patients to encourage commitment to their recovery.

Conclusion

A well-constructed and routinely reviewed Plan of Care not only guides effective treatment but also serves as an educational and motivational tool for patients. Sharing and discussing the plan regularly helps establish medical necessity and demonstrates the value of your services. 

By ensuring your POC is comprehensive, compliant, and patient-focused, you can achieve better outcomes, improve engagement, and streamline therapy processes, leaving little room for inefficiencies or scrutiny.

SPRYPT offers features such as automated documentation, customizable templates, and integrated billing, which will assist you in maintaining accurate records, setting measurable goals, and ensuring timely certifications. Get a Free Demo Today!