Magellan Healthcare

Clinical guidelines

PLAN OF CARE

Original Date: November 2, 2015

Page 1 of 3

Physical Medicine – Clinical Decision Making Last Review Date: June 2017

Guideline Number: NIA_CG_607 Last Revised Date: September 2017

Responsible Department:

Clinical Operations

Implementation Date: January 2018

1—Plan of Care 2018 Proprietary

Policy Statement

A properly documented plan of care is a required element of clinical documentation. It is

based on the initial evaluation findings and patient’s functional status and establishes the

medical necessity for treatment. The plan includes diagnoses, expected functional

outcomes, specific interventions, and evaluation of progress toward outcomes based on

follow up assessment. It is a framework to document critical thinking necessary for

evidenced based outcomes.

Initial Clinical Reviewers (ICRs) and Physician Clinical Reviewers (PCRs) must be able to

apply criteria based on individual needs and based on an assessment of the local delivery

system.

Purpose

To provide physical medicine practitioners with current documentation requirements for a

plan of care.

Scope

Physical medicine participating network practitioners, including rendering chiropractors,

physical therapists, occupational therapists, and speech therapists. This policy also applies

to out of network practitioners as dictated by the health plan.

Physical medicine participating network practitioners, including chiropractors, physical

therapists, occupational therapists, and speech language pathologists.

Definition/Background:

Plan of care must be included in the clinical documentation. Absence of this required

information is considered failure to support the medical necessity of treatment.

Plan of care must be individualized, goal-oriented, and aimed at restoring specific

functional deficits.

Plan of care elements:

o Treatment diagnosis and specific contraindications to treatment

o Baseline/current functional status/limitations, as compared to pre-episode

functional status

o Patient-specific functional goals that are measurable, attainable, time-

specific and sustainable. The initial plan of care for a musculoskeletal

condition should not exceed 4 weeks.

2— Plan of Care 2018 Proprietary

o Proposed frequency and duration of treatment within a reasonable and

generally predictable time period

o Specific therapeutic interventions to be provided: the clinical rationale for

each service, a description of the service, the area of the body the service will

be provided, goals for each service, and a time component, if

indicated.Predicted level of improvement in function (prognosis)

o Specific discharge plan

Plan of care should be reviewed at intervals appropriate to the patient and in

accordance with state and third party requirements.

Updated plan of care elements

o Time frame for current treatment period

o Total visits from start of care

o Change in objective outcome measures and standardized testing compared to

baseline and/or most recent re-assessment/updated plan of care

o Measurable progress toward each goal including whether goal has been met

or not met. Goals should be updated and modified as appropriate

o Modification of treatment interventions in order to meet goals

o Home program and self-management teaching

o Collaboration with other services/professionals

The plan of care should clearly support why the skills of a professional are needed as

opposed to discharge to self-management or non-skilled personnel without the

supervision of qualified professionals.

3— Plan of Care 2018 Proprietary

REFERENCES

Clinical documentation manual, 3rd ed. American Chiropractic Association.

Clinical practice guideline: medical record documentation. ASHA CPG UM 110. Sept. 20,

2007

CMS Evaluation and Management Services Guide-2015. https://www.cms.gov/Outreach-

and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-

serv-guide-ICN006764.pdf

Defensible Documentation for Patient/Client Management (www.apta.org)

DOI: http://dx.doi.org/10.1016/j.jmpt.2008.04.007

Gregory A. Baker, DC, Ronald J. Farabaugh, DC, Thomas J. Augat, DC, MS, CCSP, FASA

Cheryl Hawk, DC, PhD, CHES. Algorithms for the Chiropractic Management of Acute

and Chronic Spine-Related Pain. Topics in Integrative Health Care 2012, Vol. 3(4) ID:

3.4007

Guidelines for Documentation of Occupational Therapy (www.aota.org)

Guidelines: Physical Therapy Documentation of Patient/Client Management BOD G03-05-

16-41 (www.apta.org.)

Khorsan R., Coulter IA., Hawk C., Goertz-Choate. (2008) Measures in Chiropractic

Research: Choosing Patient-Based Outcome Assessments. JMPT June 2008 Volume 31,

Issue 5, Pages 355–375. http://dx.doi.org/10.1016/j.jmpt.2008.04.007

Medicare Benefit Policy Manual, Chapter 16, 240.1.2 A- 240.1.3; Documentation

Requirements

Paul D., Hasselkus A. (2004) Clinical Record keeping in Speech-Language Pathology for

Health Care and Third-Party Payers (www.asha.org)

Recommendations for Chiropractic Documentation, Wisconsin Chiropractic Association.

Treatment Plan for Chiropractic Manipulation Services. WPS Government Health

Administrators.

Yeomans SG. The clinical application of outcomes assessment. Appleton & Lange; 2000

Yeomans SG., Liebenson C. Applying Outcomes Management to Clinical Practice. JNMS:

Journal of the Neuromusculoskeletal System Vol. 5, No. 1.

https://www.yeomanschiropracticeducation.com/PDF%20files/09ClinicalApplication3908

5A.pdf

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• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as:• Qualified interpreters• Information written in other languages

If you need these services, contact a Grievance Specialist.

If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Grievance SpecialistPreferredOne Insurance CompanyPO Box 59212Minneapolis, MN 55459-0212Phone: 1.800.940.5049 (TTY: 763.847.4013)Fax: 763.847.4010customerservice@preferredone.com

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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