LifeCare Physical)Therapy) ! Plan)of)Treatment) FI PT Package... · LifeCare Therapy Services...
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LifeCare Therapy Services Rehabilitation Therapy and Disease Management PT Plan of Treatment Page 1 of 2 Revised: 01/2013 Physical Therapy Plan of Treatment Patient’s Last Name First Name MI HICN Provider Name LifeCare of Florida Provider No Onset Date SOC Date Primary Diagnosis(es) Treatment Diagnosis(es) Clinical Interview The Interview was completed with: Patient Spouse Caregiver Other: _______________________________________________________________ Patient Age: ___________ Years Mental Status: Alert Oriented x __________ Impaired: _____________________________________________ Living Situation The patient resides in a: Home Apt/Condo ILF ALF or Other: ________________________________________________________________ Accessibility: Level Ramped Steps: _______ To Enter _______ In Home Concerns: ________________________________________________________ The patient lives: Alone or with Spouse Family Caregiver ________________________ (Hours/Days) Other: __________________________________ Who currently helps with ADLs? _____________________________________________________________________________________________________________ Reason for Referral/Symptom Onset Medical History/Medications Additional Complexities that Impact Care Assistive Device History Prior to the onset of the current condition, Patient utilized: (List equipment used): _______________________________________________________________ Currently Patient utilizes: __________________________________________________________________________________________________________________ Comments (Address safety and effective use of equipment): ______________________________________________________________________________________ Fall History & Risk Assessment Patient has had falls. The last fall occurred on (date): __________________________ Location: ___________________________________________________ which resulted in (Describe injury or condition): ___________________________________________________________________________________________ Patient is at risk for falls due to: Loss of balance Poor postural alignment/control Difficulty walking Freezing when walking Is patient able to call for help? Yes No Comments: ______________________________________________________________________________ Rehabilitation History No prior therapy (PT, OT, SLP) appears to have been provided in the past 12 months or, Patient has received PT OT SLP in the last 12 months for the current or a previous condition Describe: __________________________________________________________________________________________________________________________ Patient is not currently receiving home health services
Transcript of LifeCare Physical)Therapy) ! Plan)of)Treatment) FI PT Package... · LifeCare Therapy Services...
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
PT Plan of Treatment Page 1 of 2 Revised: 01/2013
Physical Therapy Plan of Treatment
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date
Primary Diagnosis(es) Treatment Diagnosis(es)
Clinical Interview The Interview was completed with: Patient Spouse Caregiver Other: _______________________________________________________________ Patient Age: ___________ Years Mental Status: Alert Oriented x __________ Impaired: _____________________________________________
Living Situation The patient resides in a: Home Apt/Condo ILF ALF or Other: ________________________________________________________________ Accessibility: Level Ramped Steps: _______ To Enter _______ In Home Concerns: ________________________________________________________ The patient lives: Alone or with Spouse Family Caregiver ________________________ (Hours/Days) Other: __________________________________ Who currently helps with ADLs? _____________________________________________________________________________________________________________
Reason for Referral/Symptom Onset
Medical History/Medications Additional Complexities that Impact Care Assistive Device History Prior to the onset of the current condition, Patient utilized: (List equipment used): _______________________________________________________________ Currently Patient utilizes: __________________________________________________________________________________________________________________ Comments (Address safety and effective use of equipment): ______________________________________________________________________________________
Fall History & Risk Assessment Patient has had falls. The last fall occurred on (date): __________________________ Location: ___________________________________________________ which resulted in (Describe injury or condition): ___________________________________________________________________________________________ Patient is at risk for falls due to: Loss of balance Poor postural alignment/control Difficulty walking Freezing when walking Is patient able to call for help? Yes No Comments: ______________________________________________________________________________
Rehabilitation History No prior therapy (PT, OT, SLP) appears to have been provided in the past 12 months or, Patient has received PT OT SLP in the last 12 months for the current or a previous condition Describe: __________________________________________________________________________________________________________________________ Patient is not currently receiving home health services
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Patient’s Last Name First Name
MI HICN
PT Plan of Treatment Page 2 of 2 Revised: 01/2013
Physical Therapy Plan of Treatment – Page 2
Impact on Function Prior Level of Function Independent Required Assistance (Describe) Current Level of Function (Summary from PT Evaluation)
Primary G-‐Code with Severity Modifier (Impairment)
Admit/Current Status Projected/Goal Code/Descriptor Impairment Level Code/Descriptor Impairment Level ____________________________________________
___________________
____________________________________________
____________________
Physical Therapy Plan of Care Recommended # of Visits for Skilled POC: __________Visits Frequency: _________/week Duration: __________ hours/visit Certification Period: Start: __________________ End: _____________________ (Max 90 days)
Rehabilitation Potential: Excellent Good Fair Guarded Poor Long Term Goals: (Number each goal) Skilled Intervention to Include 97110 Therapeutic Exercise 97112 Neuromuscular Re-‐Education 97116 Gait Training 97140 Manual Therapy 97542 Wheelchair Training 97761 Prosthetic Training Other: _____________________________________________________________________________________________________________________________
Additional Recommendations OT Evaluation SLP Evaluation Social Services 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 ____________________
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
PT Initial Evaluation Page 1 of 2 Revised: 01/2014
Physical Therapy Evaluation
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
Onset Date SOC Date
Primary Diagnosis(es) Treatment Diagnosis(es)
Musculoskeletal Evaluation
Spinal Evaluation: NT WFL Impaired (Document Below) Area of Impairment Assessment Notes ROM MMT Sensation Pain Cervical ________ ________ ________ _____/10 ___________________________________________________________ Thoracic ________ ________ ________ _____/10 ___________________________________________________________ Lumbar ________ ________ ________ _____/10 ___________________________________________________________
Upper Body: NT WFL Impaired (Document Below) Area of Impairment Assessment Notes ROM MMT Tone Sensation Edema Pain RIGHT: Shoulder ________ ________ ________ ________ ________ _____/10 _____________________________________ Elbow ________ ________ ________ ________ ________ _____/10 _____________________________________ Wrist/Hand ________ ________ ________ ________ ________ _____/10 _____________________________________ LEFT: Shoulder ________ ________ ________ ________ ________ _____/10 _____________________________________ Elbow ________ ________ ________ ________ ________ _____/10 _____________________________________ Wrist/Hand ________ ________ ________ ________ ________ _____/10 _____________________________________
Lower Body: NT WFL Impaired (Document Below) Area of Impairment Assessment Notes ROM MMT Tone Sensation Edema Pain RIGHT: Hip ________ ________ ________ ________ ________ _____/10 _____________________________________ Knee ________ ________ ________ ________ ________ _____/10 _____________________________________ Ankle/Foot ________ ________ ________ ________ ________ _____/10 _____________________________________ LEFT: Hip ________ ________ ________ ________ ________ _____/10 _____________________________________ Knee ________ ________ ________ ________ ________ _____/10 _____________________________________ Ankle/Foot ________ ________ ________ ________ ________ _____/10 _____________________________________
Posture: NT WFL Impaired (Describe)
Gait: NT WFL Impaired (Describe both gait pattern and ambulatory capacity)
Endurance/Dyspnea: None Mild Moderate Severe Assessment Notes
At Rest / Lying Down __________________________________________ For ADLs __________________________________________
Patient’s Last Name First Name
MI HICN
PT Initial Evaluation Page 2 of 2 Revised: 01/2014
Functional Evaluation
Test(s) Administered: Tinetti Gait/Balance BERG Balance Scale Functional Reach Test NDI Oswestry OPTIMAL Other: ________________________________________________________________________________________ Test Results: Score: ____________ Interpretation: __________________________________________________________________________________
Functional Scoring Guidelines (FIM)
7=Independent 6=Modified Independent 5=Supervision 4=Min Assist (25%) 3=Mod Assist (50%) 2=Max Assist (75%) 1=Total Assist (76% or >)
Prior Current Level of Function (LOF) Goal Able to Perform Needs Assistance Notes
Indep Difficult/
Unsafe Level of Assist Total
Balance Sit Unsupported _______ _______ _________________________________ ________
Stand Unsupported _______ _______ _________________________________ ________
Dynamic/Challenged _______ _______ _________________________________ ________
Transfer Bed/Chair _______ _______ _________________________________ ________ Chair/Stand _______ _______ _________________________________ ________ Toilet _______ _______ _________________________________ ________ Car _______ _______ _________________________________ ________
Ambulation In Room _______ _______ _________________________________ ________ In Home _______ _______ _________________________________ ________ In Community _______ _______ _________________________________ ________ Up/Down Stairs _______ _______ _________________________________ ________
Functional Mobility Self Care _______ _______ _________________________________ ________ Light Lifting (e.g., pot) _______ _______ _________________________________ ________ Heavy Lift (e.g., groceries or laundry) _______ _______ _________________________________ ________ Bend to Floor _______ _______ _________________________________ ________ Drive _______ _______ _________________________________ ________
Other:
___________________ _______ _______ _________________________________ ________
___________________ _______ _______ _________________________________ ________
Additional Findings:
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Physical 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 Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _____________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97001 PT Evaluation
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97116 Gait Training
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Physical Therapy Functional G-‐Code Tracking Log
Patient’s Last Name First Name
MI HICN
Provider Name LifeCare of Florida
Provider No
SOC Date Discharge Date
Primary Diagnosis(es) Treatment Diagnosis(es)
Therapist: Assistant if Applicable:
Date Assessed
Visit Primary Functional Limitation
Severity Modifier
_____________ Admit/Evaluation _________________________________________________ _____________________
_____________ Progress Report _________________________________________________ _____________________
_____________ Progress Report _________________________________________________ _____________________
_____________ Progress Report _________________________________________________ _____________________
_____________ Re-Cert/Change _________________________________________________ _____________________
_____________ Discharge/Final _________________________________________________ _____________________
Goal _________________________________________________ _____________________ Notes (Document Change(s) to Primary G-‐Code)
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%
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
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
Physical Therapy Supervisory Progress Report
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Physical 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 Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _____________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97001 PT Evaluation
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97116 Gait Training
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist 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 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
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
Physical Therapy Supervisory Progress Report
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Physical 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 Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _____________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97001 PT Evaluation
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97116 Gait Training
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist 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 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
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
Physical Therapy Supervisory Progress Report
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Physical 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 Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _____________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97001 PT Evaluation
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97116 Gait Training
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
PT Re-‐Certification of the Plan of Care Revised: 01/2013
Physical Therapy Re-‐Certification of the Plan of Care
Patient’s Last Name First Name
MI HICN
XXX-‐XX-‐ 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
Physical 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 97110 Therapeutic Exercise 97112 Neuromuscular Re-‐Education 97116 Gait Training 97140 Manual Therapy 97542 Wheelchair Training 97761 Prosthetic Training 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
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
Physical Therapy Discharge Summary
LifeCare Therapy Services
Rehabi l i ta t ion Therapy and Disease Management
Physical 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 Progress/Sup Visit Discharge Assessment Skilled Therapy Other: _____________________
Billing & Coding Summary
Intake Information __________ Time _________ Units
97001 PT Evaluation
__________ Time _________ Units
97110 Therapeutic Exercise
__________ Time _________ Units
97112 Neuromuscular Re-‐Education
__________ Time _________ Units
97116 Gait Training
__________ Time _________ Units
97140 Manual Therapy
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Other: __________________________
__________ Time _________ Units
Total Time (Minutes)
Total Units
Therapist Name & Credentials (Please Print) ___________________________________________________
Therapist Signature X____________________________________________________
Date ____________________
