OAR 410-131-0080: Therapy Plan of Care and Record Requirements

(1) There must be a rehabilitative or habilitative therapy plan of care to receive payment. (2) The Division shall authorize for the level of care or type of service that meets the client’s medical need consistent with the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List) and guideline notes. (3) The rehabilitative or habilitative therapy plan must adhere to the licensing board requirements of care and shall include: (a) Client's name, ICD diagnosis code, and type, amount, frequency, and duration of the proposed rehabilitative or habilitative therapy; (b) Individualized, measurably objective functional goals; (c) Documented need for extended service, considering 60 minutes as the maximum length of a treatment session; (d) Plan to address implementation of a home management program as appropriate from the initiation of therapy forward; (e) Dated signature of the therapist or the prescribing practitioner establishing the therapy plan of care; and (f) For home health clients, any additional requirements included in OAR chapter 410 division 127. (4) The therapy treatment plan and regimen shall be taught to the client, family, foster parents, or caregiver during the therapy treatments. The client must be present for demonstrating therapy during teaching to assure therapy regimen is performed safely and correctly. The division may not authorize extra treatments for teaching. (5) A therapy plan must comply with the relevant state licensing authority’s standards. (6) If a state licensing authority has not adopted therapy plan of care standards, the therapy plan of care shall include: (a) The need for continuing rehabilitative or habilitative therapy clearly stated; (b) Changes to the rehabilitative or habilitative therapy plan of care, including changes to duration and frequency of intervention; and (c) Any changes or modifications to the therapy plan of care shall be documented, signed, and dated by the prescribing practitioner or therapist who developed the plan. (7) Therapy records shall include: (a) A written referral, including: (A) The client's name; (B) The ICD-10-CM diagnosis code; and (C) Specification of the type of services, amount, and duration required. (b) A copy of the signed therapy plan of care must be on file in the provider's therapy record prior to billing for services; (c) Documents, evaluations, re-evaluations, and progress notes to support the rehabilitative or habilitative therapy treatment plan and prescribing provider's written orders for changes in the therapy treatment plan; (d) Modalities used on each date of service; (e) Procedures performed, and amount of time spent performing the procedures, documented and signed by the therapist; and (f) Documentation of splint fabrication and time spent fabricating the splint.