CMS Pub. 100-02, ch. 15, § 220.1.3

Therapy Plans of Care

(Rev. 88, Issued: 05-07-08, Effective: 01-01-08, Implementation: 06-09-08)

Reference: 42CFR424.24(c)

See specific certification rules in Pub. 100-01, chapter 4, §20 for hospital services.

A. Method and Disposition of Certifications

Certification requires a dated signature on the plan of care or some other document that

indicates approval of the plan of care. It is not appropriate for a physician/NPP to certify

a plan of care if the patient was not under the care of some physician/NPP at the time of

the treatment or if the patient did not need the treatment. Since delayed certification is

allowed, the date the certification is signed is important only to determine if it is timely or

delayed. The certification must relate to treatment during the interval on the claim.

Unless there is reason to believe the plan was not signed appropriately, or it is not timely,

no further evidence that the patient was under the care of a physician/NPP and that the

patient needed the care is required.

The format of all certifications and recertifications and the method by which they are

obtained is determined by the individual facility and/or practitioner. Acceptable

documentation of certification may be, for example, a physician’s progress note, a

physician/NPP order, or a plan of care that is signed and dated by a physician/NPP, and

indicates the physician/NPP is aware that therapy service is or was in progress and the

physician/NPP makes no record of disagreement with the plan when there is evidence the

plan was sent (e.g., to the office) or is available in the record (e.g., of the institution that

employs the physician/NPP) for the physician/NPP to review. For example, if during the

course of treatment under a certified plan of care a physician sends an order for continued

treatment for 2 more weeks, contractors shall accept the order as certification of

continued treatment for 2 weeks under the same plan of care. If the new certification is

for less treatment than previously planned and certified, this new certification takes the

place of any previous certification. At the end of the 2 weeks of treatment (which might

extend more than 2 calendar weeks from the date the order/certification was signed)

another certification would be required if further treatment was documented as medically

necessary.

The certification should be retained in the clinical record and available if requested by the

contractor.

B. Initial Certification of Plan

The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of

the certification requirements noted above in §220.1 for the duration of the plan of care,

or 90 calendar days from the date of the initial treatment, whichever is less. The initial

treatment includes the evaluation that resulted in the plan.

Timing of Initial Certification. The provider or supplier (e.g., facility, physician/NPP, or

therapist) should obtain certification as soon as possible after the plan of care is

established, unless the requirements of delayed certification are met. “As soon as

possible” means that the physician/NPP shall certify the initial plan as soon as it is

obtained, or within 30 days of the initial therapy treatment. Since payment may be

denied if a physician does not certify the plan, the therapist should forward the plan to the

physician as soon as it is established. Evidence of diligence in providing the plan to the

physician may be considered by the Medicare contractor during review in the event of a

delayed certification.

Timely certification of the initial plan is met when physician/NPP certification of the plan

is documented, by signature or verbal order, and dated in the 30 days following the first

day of treatment (including evaluation). If the order to certify is verbal, it must be

followed within 14 days by a signature to be timely. A dated notation of the order to

certify the plan should be made in the patient’s medical record.

Recertification is not required if the duration of the initially certified plan of care is more

than the duration (length) of the entire episode of treatment.

C. Review of Plan and Recertification

Reference: 42CFR424.24(c), 1861(r), 42CFR 410.61(e).

The timing of recertification changed on January 1, 2008. Certifications signed on or

after January 1, 2008, follow the rules in this section. Certifications signed on or prior to

December 31, 2007, follow the rule in effect at that time, which required recertification

every 30 calendar days.

Payment and coverage conditions require that the plan must be reviewed, as often as

necessary but at least whenever it is certified or recertified to complete the certification

requirements. It is not required that the same physician/NPP who participated initially in

recommending or planning the patient’s care certify and/or recertify the plans.

Recertifications that document the need for continued or modified therapy should be

signed whenever the need for a significant modification of the plan becomes evident, or

at least every 90 days after initiation of treatment under that plan, unless they are delayed.

Physician/NPP Options for Certification. A physician/NPP may certify or recertify a

plan for whatever duration of treatment the physician/NPP determines is appropriate, up

to a maximum of 90 calendar days. Many episodes of therapy treatment last less than 30

calendar days. Therefore, it is expected that the physician/NPP should certify a plan that

appropriately estimates the duration of care for the individual, even if it is less than 90

days. If the therapist writes a plan of care for a duration that is more or less than the

duration approved by the physician/NPP, then the physician/NPP would document a

change to the duration of the plan and certify it for the duration the physician/NPP finds

appropriate (up to 90 days). Treatment beyond the duration certified by the

physician/NPP requires that a plan be recertified for the extended duration of treatment.

It is possible that patients will be discharged by the therapist before the end of the

estimated treatment duration because some will improve faster than estimated and/or

some were successfully progressed to an independent home program.

Physicians/NPPs may require that the patient make a physician/NPP visit for an

examination if, in the professional’s judgment, the visit is needed prior to certifying the

plan, or during the planned treatment. Physicians/NPPs should indicate their requirement

for visits, preferably on an order preceding the treatment, or on the plan of care that is

certified. If the physician wishes to restrict the patient’s treatment beyond a certain date

when a visit is required, the physician should certify a plan only until the date of the visit.

After that date, services will not be considered reasonable and necessary due to lack of a

certified plan. Physicians/NPPs should not sign a certification if they require a visit and a

visit was not made. However, Medicare does not require a visit unless the National

Coverage Determination (NCD) for a particular treatment requires it (e.g., see Pub. 100-

03, §270.1 - Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment

of Wounds).

Restrictions on Certification. Certifications and recertifications by doctors of podiatric

medicine must be consistent with the scope of the professional services provided by a

doctor of podiatric medicine as authorized by applicable state law. Optometrists may

order and certify only low vision services. Chiropractors may not certify or recertify

plans of care for therapy services.

D. Delayed Certification

References: §1835(a) of the Act

42CFR424.11(d)(3)

Certifications are required for each interval of treatment based on the patient’s needs, not

to exceed 90 calendar days from the initial therapy treatment. Certifications are timely

when the initial certification (or certification of a significantly modified plan of care) is

dated within 30 calendar days of the initial treatment under that plan. Recertification is

timely when dated during the duration of the initial plan of care or within 90 calendar

days of the initial treatment under that plan, whichever is less. Delayed certification and

recertification requirements shall be deemed satisfied where, at any later date, a

physician/NPP makes a certification accompanied by a reason for the delay.

Certifications are acceptable without justification for 30 days after they are due. Delayed

certification should include one or more certifications or recertifications on a single

signed and dated document.

Delayed certifications should include any evidence the provider or supplier considers

necessary to justify the delay. For example, a certification may be delayed because the

physician did not sign it, or the original was lost. In the case of a long delayed

certification (over 6 months), the provider or supplier may choose to submit with the

delayed certification some other documentation (e.g., an order, progress notes, telephone

contact, requests for certification or signed statement of a physician/NPP) indicating need

for care and that the patient was under the care of a physician at the time of the treatment.

Such documentation may be requested by the contractor for delayed certifications if it is

required for review.

It is not intended that needed therapy be stopped or denied when certification is delayed.

The delayed certification of otherwise covered services should be accepted unless the

contractor has reason to believe that there was no physician involved in the patient’s care,

or treatment did not meet the patient’s need (and therefore, the certification was signed

inappropriately).

EXAMPLE: Payment should be denied if there is a certification signed 2 years after

treatment by a physician/NPP who has/had no knowledge of the patient when the medical

record also shows e.g., no order, note, physician/NPP attended meeting, correspondence

with a physician/NPP, documentation of discussion of the plan with a physician/NPP,

documentation of sending the plan to any physician/NPP, or other indication that there

was a physician/NPP involved in the case.

EXAMPLE: Payment should not be denied, even when certified 2 years after treatment,

when there is evidence that a physician approved needed treatment, such as an order,

documentation of therapist/physician/NPP discussion of the plan, chart notes, meeting

notes, requests for certification, certifications for intervals before or after the service in

question, or physician/NPP services during which the medical record or the patient’s

history would, in good practice, be reviewed and would indicate therapy treatment is in

progress.

EXAMPLE: Subsequent certifications of plans for continued treatment for the same

condition in the same patient may indicate physician certification of treatment that

occurred between certification dates, even if the signature for one of the plans in the

episode is delayed. If a certified plan of care ends March 30th and a new plan of care for

continued treatment after March 30th is developed or signed by a therapist on April 15th

and that plan is subsequently certified, that certification may be considered delayed and

acceptable effective from the first treatment date after March 30th for the frequency and

duration as described in the plan. Of course, documentation should continue to indicate

that therapy during the delay is medically necessary, as it would for any treatment. The

certification of the physician/NPP is interpreted as involvement and approval of the

ongoing episode of treatment, including the treatment that preceded the date of the

certification unless the physician/NPP indicates otherwise.

E. Denials Due to Certification

Denial for payment that is based on absence of certification is a technical denial, which

means a statutory requirement has not been met. Certification is a statutory requirement

in SSA 1835(a)(2)- (‘periodic review” of the plan).

For example, if a patient is treated and the provider/supplier cannot produce (on

contractor request) a plan of care (timely or delayed) for the billed treatment dates

certified by a physician/NPP, then that service might be denied for lack of the required

certification. If an appropriate certification is later produced, the denial shall be

overturned.

In the case of a service furnished under a provider agreement as described in

42CFR489.21, the provider is precluded from charging the beneficiary for services

denied as a result of missing certification.

However, if the service is provided by a supplier (in the office of the physician/NPP, or

therapist) a technical denial due to absence of a certification results in beneficiary

liability. For that reason, it is recommended that the patient be made aware of the need

for certification and the consequences of its absence.

A technical denial decision may be reopened by the contractor or reversed on appeal as

appropriate, if delayed certification is later produced.