Occupational+Therapy++ ! ! Plan+of+Treatment!!
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Occupational Therapy Plan of Treatment Patient’s Last Name First Name MI HICN XXXXX Provider Name LifeCare of Florida Provider No Onset Date SOC Date Primary Diagnosis Treatment Diagnosis Reason for Referral/Symptom Onset The Interview was completed with Patient Spouse Caregiver Other: ________________________________________________ Patient is _______ Years of Age and resides in a Home Apt/Condo ILF ALF Other: ________________________________________ Home is Accessible Not Accessible Has Steps _____ To Enter or _____ In Home Concerns: ________________________________________________________________________________________________________________ The patient lives: Alone or With: Spouse Family FT Caregiver PT Caregiver ____________________________________ hours/days) Who Currently Helps with ADLs? _____________________________________________________________________________________________ Summary: Patient presents with a history of _____ Low _____ Moderate _____ High Complexity Body Systems Affected: Skeletal Muscular Nervous CardioRespiratory Lymphatic Other: _____________________ Body Regions Affected: Multiple Sites/Systemic Dominant Side: R L Right Shoulder Elbow/Upper Arm Wrist/Forearm Fingers & Hand Hip Knee/Lower Leg Ankle/Foot Left Shoulder Elbow/Upper Arm Wrist/Forearm Fingers & Hand Hip Knee/Lower Leg Ankle/Foot Other: Head Cervical Spine Thoracic Spine Lumbar Spine Ribs CoMorbid Medical Complexities: (Conditions which directly and significantly impact the patient’s level of function) No Yes (Describe): Additional Medical Hx / Medications Injury & Fall History Patient has had (Check all that apply): Loss of Balance/Near Falls Falls w/out Injury Falls with Injury If Injury Occurred: When (date): ____________________ Location: ______________________________ Activity: ________________________ Injury: __________________________________________________ Is this the condition for which skilled therapy was ordered? No Yes Rehab History Patient Has Not or HAS received PT OT SLP in the past 12 months, Therapy was for current or previous condition. Describe: _________________________________________________________________________________________________________________ Prior Level of Function Independent OR Required Assistance (Describe)
Transcript of Occupational+Therapy++ ! ! Plan+of+Treatment!!
Occupational Therapy Plan of Treatment
Patient’s Last Name First Name
MI HICN XXX-‐XX-‐
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date
Primary Diagnosis Treatment Diagnosis
Reason for Referral/Symptom Onset The Interview was completed with Patient Spouse Caregiver Other: ________________________________________________ Patient is _______ Years of Age and resides in a Home Apt/Condo ILF ALF Other: ________________________________________ Home is Accessible Not Accessible Has Steps _____ To Enter or _____ In Home Concerns: ________________________________________________________________________________________________________________ The patient lives: Alone or With: Spouse Family FT Caregiver PT Caregiver ____________________________________ hours/days)
Who Currently Helps with ADLs? _____________________________________________________________________________________________ Summary: Patient presents with a history of _____ Low _____ Moderate _____ High Complexity
Body Systems Affected: Skeletal Muscular Nervous Cardio-‐Respiratory Lymphatic Other: _____________________
Body Regions Affected: Multiple Sites/Systemic Dominant Side: R L
Right Shoulder Elbow/Upper Arm Wrist/Forearm Fingers & Hand Hip Knee/Lower Leg Ankle/Foot
Left Shoulder Elbow/Upper Arm Wrist/Forearm Fingers & Hand Hip Knee/Lower Leg Ankle/Foot
Other: Head Cervical Spine Thoracic Spine Lumbar Spine Ribs
Co-‐Morbid Medical Complexities: (Conditions which directly and significantly impact the patient’s level of function) No Yes (Describe):
Additional Medical Hx / Medications
Injury & Fall History Patient has had (Check all that apply): Loss of Balance/Near Falls Falls w/out Injury Falls with Injury
If Injury Occurred: When (date): ____________________ Location: ______________________________ Activity: ________________________
Injury: __________________________________________________ Is this the condition for which skilled therapy was ordered? No Yes
Rehab History Patient Has Not or HAS received PT OT SLP in the past 12 months, Therapy was for current or previous condition.
Describe: _________________________________________________________________________________________________________________
Prior Level of Function Independent OR Required Assistance (Describe)
Patient’s Last Name First Name
MI HICN
Current Impairments & Functional Impact
Body Functions Affected: Sensory Functions & Pain Neuro-‐Musculoskeletal & Movement CardioRespiratory/Hematological Mental Voice & Speech Skin & Related Digestive/Metabolic/Endocrine Genitourinary & Reproductive
Resulting Activity & Participation Restrictions: Balance Transfers Mobility in Home Mobility in Community Self Care/ADLs IADLS Learning & Applying Knowledge
General Tasks & Demands Communication Interpersonal Relationships Community/Social/Civic Life Being Alone
Additional Complexities: Advanced Age Time Since Onset Significant Co-‐Morbidities Fall Risk Lack/Limited Caregiver Safety in Home
Poor Vision HOH Cognitive Status Speech/Communication Bowel/Bladder Motivation Other: ______________
Primary G-‐Code The Primary G-‐Code Category for which therapy will be rendered is: _______________________________________________________________
Patient’s Admit Impairment Level is: __________________________________ with a Goal of ____________________________________________
Occupational Therapy Plan of Care Recommended # of Skilled Therapy Visits: ___________ Visits Frequency: _________/week Duration: ____________ hours/visit Certification Period: Start: ________________________ End: ___________________ (Max 90 Days) Rehabilitation Potential: Excellent Good Fair Poor Long Term Goals: (Number Each Goal)
Skilled Intervention to Include: 97535 Self-‐Care/Home Mngt Training 97110 Therapeutic Exercise
97532 Cognitive Skills Training 97112 Neuromuscular Re-‐Education
97533 SI Training 97140 Manual Therapy
Other: _______________________________________________________________________________________________________________ Precautions/Contraindications: ___________________________________________________________________________________________
Additional Recommendations: PT Evaluation SLP Evaluation Adaptive Equipment: ___________________________________________________________________ Medical Follow-‐Up For: _________________________________________________________________________________________________ Other: _______________________________________________________________________________________________________________
Professionals Establishing This Plan of Care Therapist Name & Credentials (Please Print) ______________________________________________________
Therapist Signature X_____________________________________________________
Date ____________________
As of the date of this evaluation, I certify the pertinent medical history and the need for skilled services that have been completed in consultation with the evaluating therapist under this plan.
Physician Name (Please Print) ___________________________________________________
Physician Signature X____________________________________________________
Date ____________________
Occupational Therapy Plan of Treatment – Page 2
Patient’s Last Name First Name
MI HICN XXX-‐XX-‐
Diagnosis: SOC Date
Evaluating Therapist:
Musculoskeletal Evaluation Assessment Of: Cervical Spine Lumbar Spine Upper Body Lower Body Other: ______________________________________
Symptoms/Complaints:
Pain ___ None or: ____/10 Average ____/10 Worst ____/10 Best
ROM: WFL or Impaired
MMT: WFL or Impaired
Muscle Tone: WFL or Impaired: Flaccid Hypotonic Hypertonic
Sensation: WFL or Impaired for: Light Touch Pain Proprioception
Edema: Not Present or Present
Palpation: N/A or Describe Below
Special Tests: None or Describe Below
Endurance: Good Fair Poor (Describe Activity Tolerance in Minutes)
Posture: No Abnormality or Impaired
Deviations: Kyphosis Lordosis Scoliosis Forward Head Protracted Shoulders Leg Length Discrepancy
Other Pertinent Findings:
Occupational Therapy Evaluation
Patient’s Last Name First Name
MI HICN
OT Initial Evaluation Page 2 of 2 Revised: 10/2014
Occupational Performance Evaluation Scoring Guidelines: 7=Indep 6=Modified Indep 5=Supervision 4=Min Assist 3=Mod Assist 2=Max Assist 1=Total Assist
Systems Review: Yes No Assessment Notes
Vision: Sufficient with or without glasses to read medication labels, newspaper and watch TV _____ _____ ____________________________________________________________ Hearing: Able to hear normal conversational voice with or without hearing aide _____ _____ ____________________________________________________________ Memory – Short Term: Intact for short term recall of information _____ _____ ___________________________________________________________ Memory – Long Term: Accurate recall of pertinent facts and information _____ _____ ___________________________________________________________ Mood: Reports signs and/or demonstrates symptoms of depression _____ _____ ___________________________________________________________ Sleep: Reports adequate sleep pattern _____ _____ ___________________________________________________________ Other: ______________________________________________ _____ _____ ___________________________________________________________
Activities of Daily Living: Prior LOF
Eval LOF Assessment Notes
Goal LOF
Bathing: Able to get in/out of tub/shower safely, wash body and hair ______ ______ ___________________________________________________ ______ Upper Body Dressing: Gets clothes from closets and drawers, able to don/doff safely including fasteners/buttons ______ ______ ___________________________________________________ ______ Lower Body Dressing: Gets clothes from closets and drawers, including underclothes, able to don/doff safely including socks and shoes ______ ______ ___________________________________________________ ______ Toileting: Able to use toilet, clean self and arrange clothes without assistance ______ ______ ___________________________________________________ ______ Upper Body Hygiene: Able to stand or be stable at sink to wash face and hands, brush teeth and comb hair ______ ______ ___________________________________________________ ______ Continence: Controls urination and bowels completely by self without accidents ______ ______ ___________________________________________________ ______ Feeding: Able to feed self meal, bring food to mouth and use utensils including cutting meat and buttering bread ______ ______ ___________________________________________________ ______ Transfers: Safely moves in and out of bed, up/down from toilet and in/out of bath without assistance ______ ______ ___________________________________________________ ______ Personal Device Care: Able to don/doff, care for and appropriately utilize personal device ______ ______ ___________________________________________________ ______
Instrumental ADLs: Prior LOF
Eval LOF Assessment Notes
Goal LOF
Telephone: Able to operate on own initiative, look up and dial number ______ ______ ___________________________________________________ ______ Shopping: Able to take care of all shopping needs including planning, purchasing and placing food in proper storage location ______ ______ ___________________________________________________ ______ Food Preparation: Able to plan, prepare and serve adequate meals to self/family ______ ______ ___________________________________________________ ______ Housekeeping: Maintains home at acceptable level of cleanliness either alone or with only occasional help ______ ______ ___________________________________________________ ______ Laundry: Sort, wash, dry and fold independently ______ ______ ___________________________________________________ ______ Transportation: Travels independently on public transportation or drives own car ______ ______ ___________________________________________________ ______ Medications: Is responsible for taking medication in correct dosages at correct time ______ ______ ___________________________________________________ ______ Finances: Manages financial matters independently (pay bills, monitor income) ______ ______ ___________________________________________________ ______
* Adapted from the Katz Index of ADL and Instrumental Activities of Daily Living Scale
Occupational Therapy Encounter Note
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
SOC Date Date of Visit
Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Services Rendered: Intake Initial Evaluation Skilled Therapy Other: ______________________________________________________________
Billing & Coding Summary
Intake Information
__________ Time _________ Units
97165 OT Evaluation LOW Complexity
__________ Time _________ Units
97166 OT Evaluation MODERATE
__________ Time _________ Units
97167 OT Evaluation HIGH Complexity
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
97535 Self Care-‐Home Mngt Training
__________ Time _________ Units
97532 Cognitive Skills Training
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________
Evaluation Coding Guidelines Low Complexity Moderate Complexity High Complexity Occupational Profile; Medical & Therapy Review Brief Expanded Extensive Examination of Performance Deficits 1-‐2 Deficits 3-‐5 Deficits 5 or More Deficits Clinical Decision Making Low Moderate High Co-‐Morbidities None May Present Yes Task or Assistance Modification None Min-‐Moderate Significant Typical face-‐to-‐face time with patient/family 30 Minutes 45 Minutes 60 Minutes
Patient’s Last Name First Name
MI HICN XXX-‐XX-‐
Therapist: Onset Date SOC Date
Primary Diagnosis:
Injury & Fall History Patient has had (Check all that apply): Loss of Balance/Near Falls Falls w/out Injury Falls with Injury
If Injury Occurred: When (date): ____________________ Location: ______________________________ Activity: _______________________
Injury: __________________________________________________ Is this the condition for which skilled therapy was ordered? No Yes
Co-‐Morbid Medical Complexities: (Conditions which directly and significantly impact the patient’s level of function) No Yes (Describe):
Current Areas Affected Multiple Sites/Systemic Dominant Side: R L
Right Shoulder Elbow/Upper Arm Wrist/Forearm Fingers & Hand Hip Knee/Lower Leg Ankle/Foot
Left Shoulder Elbow/Upper Arm Wrist/Forearm Fingers & Hand Hip Knee/Lower Leg Ankle/Foot
Other: Head Cervical Spine Thoracic Spine Lumbar Spine Ribs
Body Functions Affected: Sensory Functions & Pain Neuro-‐Musculoskeletal & Movement CardioRespiratory/Hematological Mental Voice & Speech Skin & Related Digestive/Metabolic/Endocrine Genitourinary & Reproductive
Resulting Activity & Participation Restrictions: Balance Transfers Mobility in Home Mobility in Community Self Care/ADLs IADLS Learning & Applying Knowledge
General Tasks & Demands Communication Interpersonal Relationships Community/Social/Civic Life Being Alone
Additional Complexities: Advanced Age Time Since Onset Significant Co-‐Morbidities Fall Risk Lack/Limited Caregiver Safety in Home
Poor Vision HOH Cognitive Status Speech/Communication Bowel/Bladder Motivation Other: _____________
G-‐Code Tracking Date Assessed
Visit Primary Functional Limitation
Severity Modifier
_____________ Admit/Evaluation _________________________________________________ _____________________
_____________ Progress Report _________________________________________________ _____________________
_____________ Progress Report _________________________________________________ _____________________
_____________ Progress Report _________________________________________________ _____________________
_____________ Re-‐Cert _________________________________________________ _____________________
_____________ Discharge/Final _________________________________________________ _____________________
Goal _________________________________________________ _____________________ G-‐Code Functional Limitation Level of Impairment/Severity Modifier Current Goal D/C CH CI CJ CK CL CM CN G8978 G8979 G8980 Mobility: Moving & Walking Around 0% 1-‐19% 20-‐39% 40-‐59% 60-‐79% 80-‐99% 100%
G8981 G8982 G8983 Body Position: Changing & Maintaining 0% 1-‐19% 20-‐39% 40-‐59% 60-‐79% 80-‐99% 100%
G8984 G8985 G8986 Objects: Carrying, Handling & Moving 0% 1-‐19% 20-‐39% 40-‐59% 60-‐79% 80-‐99% 100%
G8987 G8988 G8989 Self-‐Care 0% 1-‐19% 20-‐39% 40-‐59% 60-‐79% 80-‐99% 100%
G8990 G8991 G8992 Other Primary Limitation 0% 1-‐19% 20-‐39% 40-‐59% 60-‐79% 80-‐99% 100%
G8993 G8994 G8995 Other Subsequent Limitation 0% 1-‐19% 20-‐39% 40-‐59% 60-‐79% 80-‐99% 100%
Occupational Therapy ICD-‐10 & Functional G-‐Code Tracking Log
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Revised: 01/2014
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date (Evaluation Date)
Certification Period
From:
To:
# of Visits to Date Report Period
From:
To: Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Summary of Progress LTG Admission Status Current Status LTG #1
Met
LTG #2
Met
LTG #3
Met
LTG #4
Met
LTG #5
Met
G-‐CODE Primary Functional Limitation: Severity Modifier:
Primary Functional Limitation: Severity Modifier:
Conclusions Patient has made appropriate progress toward rehabilitation goals and continued functional improvement is expected
Patient has experienced a delay/setback (Explain)
Other: _______________________________________________________________________________________________________________________________
Additional Comments
Recommendations Continue POC or Modify POC (Describe): ________________________________________________________________________________________________
Other: ______________________________________________________________________________________________________________________________
Professional Establishing This Progress Report _________________________________________________________ Therapist Name & Credentials (Please Print)
_______________________________________________________ ___________________ Therapist Signature Date
Occupational Therapy Supervisory Progress Report
Occupational Therapy Encounter Note
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
SOC Date Date of Visit
Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Services Rendered: Re-‐Evaluation Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _______________________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97168 OT Re-‐Evaluation (30 Min)
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
97535 Self Care-‐Home Mngt Training
__________ Time _________ Units
97532 Cognitive Skills Training
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________
Re-‐Evaluation Coding Requirements:
• An assessment of changes in patient functional or medical status with revised plan of care; • An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; • A revised plan of care. A formal reevaluation is performed where there is a documented change in functional status or a significant change to the plan. • Typical face-‐to-‐face time with patient/and or family: 30 Minutes
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Revised: 01/2014
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date (Evaluation Date)
Certification Period
From:
To:
# of Visits to Date Report Period
From:
To: Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Summary of Progress LTG Admission Status Current Status LTG #1
Met
LTG #2
Met
LTG #3
Met
LTG #4
Met
LTG #5
Met
G-‐CODE Primary Functional Limitation: Severity Modifier:
Primary Functional Limitation: Severity Modifier:
Conclusions Patient has made appropriate progress toward rehabilitation goals and continued functional improvement is expected
Patient has experienced a delay/setback (Explain)
Other: _______________________________________________________________________________________________________________________________
Additional Comments
Recommendations Continue POC or Modify POC (Describe): ________________________________________________________________________________________________
Other: ______________________________________________________________________________________________________________________________
Professional Establishing This Progress Report _________________________________________________________ Therapist Name & Credentials (Please Print)
_______________________________________________________ ___________________ Therapist Signature Date
Occupational Therapy Supervisory Progress Report
Occupational Therapy Encounter Note
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
SOC Date Date of Visit
Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Services Rendered: Re-‐Evaluation Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _______________________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97168 OT Re-‐Evaluation (30 Min)
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
97535 Self Care-‐Home Mngt Training
__________ Time _________ Units
97532 Cognitive Skills Training
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________
Re-‐Evaluation Coding Requirements:
• An assessment of changes in patient functional or medical status with revised plan of care; • An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; • A revised plan of care. A formal reevaluation is performed where there is a documented change in functional status or a significant change to the plan. • Typical face-‐to-‐face time with patient/and or family: 30 Minutes
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Revised: 01/2014
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date (Evaluation Date)
Certification Period
From:
To:
# of Visits to Date Report Period
From:
To: Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Summary of Progress LTG Admission Status Current Status LTG #1
Met
LTG #2
Met
LTG #3
Met
LTG #4
Met
LTG #5
Met
G-‐CODE Primary Functional Limitation: Severity Modifier:
Primary Functional Limitation: Severity Modifier:
Conclusions Patient has made appropriate progress toward rehabilitation goals and continued functional improvement is expected
Patient has experienced a delay/setback (Explain)
Other: _______________________________________________________________________________________________________________________________
Additional Comments
Recommendations Continue POC or Modify POC (Describe): ________________________________________________________________________________________________
Other: ______________________________________________________________________________________________________________________________
Professional Establishing This Progress Report _________________________________________________________ Therapist Name & Credentials (Please Print)
_______________________________________________________ ___________________ Therapist Signature Date
Occupational Therapy Supervisory Progress Report
Occupational Therapy Encounter Note
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
SOC Date Date of Visit
Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Services Rendered: Re-‐Evaluation Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _______________________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97168 OT Re-‐Evaluation (30 Min)
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
97535 Self Care-‐Home Mngt Training
__________ Time _________ Units
97532 Cognitive Skills Training
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________
Re-‐Evaluation Coding Requirements:
• An assessment of changes in patient functional or medical status with revised plan of care; • An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; • A revised plan of care. A formal reevaluation is performed where there is a documented change in functional status or a significant change to the plan. • Typical face-‐to-‐face time with patient/and or family: 30 Minutes
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
OT Re-‐Certification of the Plan of Care Revised: 01/2013
Occupational Therapy Re-‐Certification of the Plan of Care Re-‐Certification of the Plan of Care
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No Onset Date SOC Date Date of ReCert Request
Primary Diagnosis(es) Treatment Diagnosis(es)
This Re-‐Certification is To: Complete the Initial Plan of Care (No additional therapy visits are needed; only an extension of the Certification Period). Extend the initial plan of care to provide continued skilled therapy to reach the goals (additional therapy visits are requested). Revise the POC due to a substantial change in the patient’s condition (additional therapy visits are requested).
Rationale:
G-‐Code with Severity Modifier (Impairment) Current Status Projected/Goal Status
Code/Descriptor Impairment Level Code/Descriptor Impairment Level
Occupational Therapy Updated Plan of Care # of Visits to Complete Skilled POC __________Visits Frequency: _________/week Duration: __________ hours/visit Re-‐Certification Period: Start: __________________ End: _____________________ (Max 30 days)
Rehabilitation Potential: Excellent Good Fair Guarded Poor Long Term Goals: No Change OR Revised/Updated Goals Below: (Number each goal) Skilled Intervention to Include 97535 Self-‐Care/Home Mngt Training 97532 Cognitive Skills Training 97533 SI Training 97110 Therapeutic Exercise 97112 Neuromuscular Re-‐Education 97140 Manual Therapy Other: _____________________________________________________________________________________________________________________________
Additional Recommendations Medical Follow-‐Up For: ________________________________________________________________________________________________________________ Other: ______________________________________________________________________________________________________________________________
Professionals Establishing This Plan of Care Therapist Name & Credentials (Please Print) ______________________________________________________
Therapist Signature X_____________________________________________________
Date ____________________
I certify the need for skilled therapy services as described in this Updated Plan of Care that has that have been completed in consultation with the evaluating therapist under this plan.
Physician Name (Please Print) ___________________________________________________
Physician Signature X____________________________________________________
Date ____________________
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Revised: 01/2014
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date (Evaluation Date)
Certification Period
From:
To:
# of Visits to Date Date of Discharge
Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Discharge/Outcome LTG Admission Status Discharge Status LTG #1
Met
LTG #2
Met
LTG #3
Met
LTG #4
Met
LTG #5
Met
G-‐CODE Primary Functional Limitation: Severity Modifier:
Primary Functional Limitation: Severity Modifier:
Reason For Discharge Goal Attainment Maximum Benefit Failure to Respond/Plateau
Patient Request (Explain): _______________________________________________________________________________________________________________
Patient No Longer Able to Participate: ____________________________________________________________________________________________________
Additional Comments
Recommendations Home Program As Assigned Medical Follow-‐Up Other: _______________________________________________________________________________
Professional Establishing This Progress Report _________________________________________________________ Therapist Name & Credentials (Please Print)
_______________________________________________________ ___________________ Therapist Signature Date
Occupational Therapy Discharge Summary
Occupational Therapy Encounter Note
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
SOC Date Date of Visit
Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist Assistant (If Applicable)
Services Rendered: Re-‐Evaluation Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _______________________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97168 OT Re-‐Evaluation (30 Min)
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
97535 Self Care-‐Home Mngt Training
__________ Time _________ Units
97532 Cognitive Skills Training
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________
Re-‐Evaluation Coding Requirements:
• An assessment of changes in patient functional or medical status with revised plan of care; • An update to the initial occupational profile to reflect changes in condition or environment that affect future intervention and/or goals; • A revised plan of care. A formal reevaluation is performed where there is a documented change in functional status or a significant change to the plan. • Typical face-‐to-‐face time with patient/and or family: 30 Minutes
