CMS Pub. 100-01, ch. 4, § 40.1

Care Services

(Rev. 120, Issued: 11-02-18, Effective: 12- 04-18, Implementation: 12- 04-18)

A certification or recertification statement must be signed by the attending physician or a

physician on the staff of the skilled nursing facility who has knowledge of the case, or by

a physician extender (that is, a nurse practitioner, a clinical nurse specialist or, effective

with items and services furnished on or after January 1, 2011, a physician assistant) who

does not have a direct or indirect employment relationship with the facility, but who is

working in collaboration with the physician. See Pub. 100-02, Medicare Benefit Policy

Manual at chapter 8, §40.1, for a discussion of “direct” and “indirect” employment

relationships in this context, and at chapter 15, §190.C (for physician assistants), §200.D

(for nurse practitioners), and §210.D (for clinical nurse specialists), regarding the

required collaboration between the physician and the physician extender.

Ordinarily, for purposes of certification and recertification, a “physician” must meet the

definition contained in Chapter 5, §70 of this manual.