DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

PLAN OF TREATMENT FOR OUTPATIENT REHABILITATION

(COMPLETE FOR INITIAL CLAIMS ONLY)
1. PATIENT’S LAST NAME FIRST NAME M.I. 2. PROVIDER NO. 3. HICN

4. PROVIDER NAME 5. MEDICAL RECORD NO. (Optional) 6. ONSET DATE 7. SOC. DATE

8. TYPE 9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10.TREATMENT DIAGNOSIS 11. VISITS FROM SOC.
■ PT ■ OT ■ SLP ■ CR
■ RT ■ PS ■ SN ■ SW
12. PLAN OF TREATMENT FUNCTIONAL GOALS PLAN
GOALS (Short Term)

OUTCOME (Long Term)

13. SIGNATURE (professional establishing POC including prof. designation) 14. FREQ/DURATION (e.g., 3/Wk. x 4 Wk.)

I CERTIFY THE NEED FOR THESE SERVICES FURNISHED UNDER 17. CERTIFICATION
THIS PLAN OF TREATMENT AND WHILE UNDER MY CARE ■ N/A
FROM THROUGH N/A
15. PHYSICIAN SIGNATURE 16. DATE
18. ON FILE (Print/type physician’s name)

■
20. INITIAL ASSESSMENT (History, medical complications, level of function 19. PRIOR HOSPITALIZATION
at start of care. Reason for referral.)
FROM TO N/A

21. FUNCTIONAL LEVEL (End of billing period) PROGRESS REPORT ■ CONTINUE SERVICES OR ■ DC SERVICES

22. SERVICE DATES

FROM THROUGH
Form CMS-700-(11-91)
 INSTRUCTIONS FOR COMPLETION OF FORM CMS-700
(Enter dates as 6 digits, month, day, year)

1. Patient’s Name - Enter the patient’s last name, first name goals and outcome. Estimate time-frames to reach goals,
and middle initial as shown on the health insurance Medicare when possible.
card.
13. Signature - Enter the signature (or name) and the
2. Provider Number - Enter the number issued by Medicare to professional designation of the professional establishing the
the billing provider (i.e., 00–7000). plan of treatment.

3. HICN - Enter the patient’s health insurance number as shown 14. Frequency/Duration - Enter the current frequency and
on the health insurance Medicare card, certification award, duration of your treatment; e.g., 3 times per week for 4 weeks
utilization notice, temporary eligibility notice, or as reported is entered 3/Wk x 4Wk.
by SSO.
15. Physician’s Signature - If the form CMS-700 is used for
4. Provider Name - Enter the name of the Medicare billing certification, the physician enters his/her signature. If
provider. certification is required and the form is not being used for
certification, check the ON FILE box in item 18. If the
5. Medical Record No. - (optional) Enter the patient’s medical/ certification is not required for the type service rendered,
clinical record number used by the billing provider. check the N/A box.

6. Onset Date - Enter the date of onset for the patient’s primary 16. Date - Enter the date of the physician’s signature only if the
medical diagnosis, if it is a new diagnosis, or the date of the form is used for certification.
most recent exacerbation of a previous diagnosis. If the exact
date is not known enter 01 for the day (i.e., 120191). The 17. Certification - Enter the inclusive dates of the certification,
date matches occurrence code 11 on the UB-92. even if the ON FILE box is checked in item 18. Check the
N/A box if certification is not required.
7. SOC (start of care) Date - Enter the date services began at
the billing provider (the date of the first Medicare billable visit 18. ON FILE (Means certification signature and date) - Enter the
which remains the same on subsequent claims until typed/printed name of the physician who certified the plan
discharge or denial corresponds to occurrence code 35 for of treatment that is on file at the billing provider. If certification
PT, 44 for OT, 45 for SLP and 46 for CR on the UB-92). is not required for the type of service checked in item 8,
type/print the name of the physician who referred or ordered
8. Type - Check the type therapy billed; i.e., physical therapy the service, but do not check the ON FILE box.
(PT), occupational therapy (OT), speech-language pathology
(SLP), cardiac rehabilitation (CR), respiratory therapy (RT), 19. Prior Hospitalization - Enter the inclusive dates of recent
psychological services (PS), skilled nursing services (SN), or hospitalization (1st to DC day) pertinent to the patient’s
social services (SW). current plan of treatment. Enter N/A if the hospital stay does
not relate to the rehabilitation being rendered.
9. Primary Diagnosis - Enter the pertinent written medical
diagnosis resulting in the therapy disorder and relating to 20. Initial Assessment - Enter only current relevant history
50% or more of effort in the plan of treatment. from records or patient interview. Enter the major functional
limitations stated, if possible, in objective measurable terms.
10. Treatment Diagnosis - Enter the written treatment diagnosis Include only relevant surgical procedures, prior hospitalization
for which services are rendered. For example, for PT the and/or therapy for the same condition. Include only pertinent
primary medical diagnosis might be Degeneration of Cervical baseline tests and measurements from which to judge future
Intervertebral Disc while the PT treatment DX might be progress or lack of progress.
Frozen R Shoulder or, for SLP, while CVA might be the
primary medical DX, the treatment DX might be Aphasia. 21. Functional Level (end of billing period) - Enter the pertinent
If the same as the primary DX enter SAME. progress made and functional levels obtained at the end of the
billing period compared to levels shown on initial assessment.
11. Visits From Start of Care - Enter the cumulative total visits Use objective terminology. Date progress when function can
(sessions) completed since services were started at the be consistently performed. When only a few visits have been
billing provider for the diagnosis treated, through the last visit made, enter a note indicating the training/treatment rendered
on this bill. (Corresponds to UB-92 value code 50 for PT, 51 and the patient’s response if there is no change in function.
for OT, 52 for SLP, or 53 for cardiac rehab.)
22. Service Dates - Enter the From and Through dates which
12. Plan of Treatment/Functional Goals - Enter brief current represent this billing period (should be monthly). Match the
plan of treatment goals for the patient for this billing period. From and Through dates in field 6 on the UB-92. DO NOT use
Enter the major short-term goals to reach overall long-term 00 in the date. Example: 01 08 91 for January 8, 1991.
outcome. Enter the major plan of treatment to reach stated