[Code of Federal Regulations]
[Title 12, Volume 1]
[Revised as of January 1, 2003]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR486.155]

[Page 620-621]
 
                         TITLE 42--PUBLIC HEALTH
 
  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 
                 HEALTH AND HUMAN SERVICES--(Continued)
 
PART 486--CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES FURNISHED BY SUPPLIERS--Table of Contents
 
Subpart D--Conditions for Coverage: Outpatient Physical Therapy Services 
        Furnished by Physical Therapists in Independent Practice
 
Sec. 486.155  Condition for coverage: Plan of care.

    For each patient, a written plan of care is established and 
periodically reviewed by the individual who established it.
    (a) Standard: Medical history and prior treatment. The physical 
therapist obtains the following information before or at the time of 
initiation of treatment:
    (1) The patient's significant past history.
    (2) Diagnosis(es), if established.
    (3) Physician's orders, if any.
    (4) Rehabilitation goals and potential for their achievement.
    (5) Contraindications, if any.
    (6) The extent to which the patient is aware of the diagnosis(es) 
and prognosis.
    (7) If appropriate, the summary of treatment provided and results 
achieved during previous periods of physical therapy services or 
institutionalization.
    (b) Standard: Plan of care. (1) For each patient there is a written 
plan of care that is established by the physician or by the physical 
therapist who furnishes the services.
    (2) The plan indicates anticipated goals and specifies for physical 
therapy services the--
    (i) Type;
    (ii) Amount;
    (iii) Frequency; and
    (iv) Duration.
    (3) The plan of care and results of treatment are reviewed by the 
physician or by the therapist at least as often as the patient's 
condition requires, and the indicated action is taken.
    (4) Changes in the plan of care are noted in the clinical record. If 
the patient has an attending physician, the therapist who furnishes the 
services promptly notifies him or her of any change in the patient's 
condition or in the plan of care. (For Medicare patients, the plan must 
be reviewed by a

[[Page 621]]

physician in accordance with Sec. 410.61(e).)

[54 FR 38679, Sept. 20, 1989. Redesignated and amended at 60 FR 2326, 
2329, Jan. 9, 1995]