Certified Outpatient Coder (COC) Practice Exam

An active treatment plan for therapy services must encompass a comprehensive understanding of the patient's condition and the goals of the therapy. This is why the most complete option includes the diagnosis, goals, date established, and type of modality or procedure used.

Identifying the diagnosis is essential because it informs the reason for therapy and the specific issues that need to be addressed. Goals are equally important as they provide a measurable outcome that guides the therapy process, allowing both the therapist and the patient to evaluate progress. Including the date established helps create a timeline for treatment, which is critical for monitoring progress and adjusting the treatment plan as necessary. Finally, noting the type of modality or procedure allows for clarity regarding the specific therapeutic approaches being utilized, which is vital for documentation and continuity of care.

In contrast, simply naming only the type of modality used does not provide enough context for treatment. Goals and diagnosis alone omit necessary factors such as treatment specifics and timelines, and identifying only the procedure and date lacks the holistic view required for effective therapy planning. Thus, option B is the most thorough and appropriate choice for an active treatment plan in therapy services.