Does CMS Require an Order for Outpatient Therapy
There is a myth that the Medicare program requires a physician order that will then allow the Medicare beneficiary to begin and/or continue outpatient physical, occupational and/or speech therapy services. Why do I say this is a myth? Lets find out.
Question
Does the Centers for Medicare and Medicaid Services (CMS) require a physician order for outpatient therapy?
Answer
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Question
Why might it be beneficial for a Medicare beneficiary to have an order prior to beginning outpatient physical, occupational and/or speech therapy services?
Answer
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Question
Is there another reason an order might be beneficial for a Medicare beneficiary to have an order prior to beginning outpatient physical, occupational and/or speech therapy services?
Answer
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Question
If I do not have direct access in my state, would I need an order to begin outpatient therapy on a Medicare beneficiary?
Answer
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Question
If I have direct access in my state and a Medicare beneficiary begins outpatient therapy services without a physician order, who do I put down as the referring physician on the claim form that I submit to my Medicare Administrative Contractor?
Answer
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Question
If I only see a Medicare beneficiary for an evaluation, provide no treatment and then discharge them, what is required in terms of a physician order or a certified plan of care?
Answer
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Question
Can one physician write an order for outpatient therapy and a different physician certify and/or recertify the plan of care?
Answer
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Question
Can one physician sign and date the initial certification for outpatient therapy and a different physician recertify the plan of care?
Answer
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All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.
This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.
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is the above true for out patient rehab facilities (ORF)as well?
You would want to read the Conditions of Participation for a Rehab Agency to see if an order is required prior to initiating outpatient therapy services.
Thank you for this clarification. Can you answer this question — If a PT or OT eval only is done for a Medicare patient, do you need a referring physician in order to bill this to Medicare? Our billing company is saying that there must be a referring physician to bill Medicare for evaluations.
I have added additional questions to this article that will answer your question.
In Virginia, if we do not have a referring physician’s name or the date that they were last seen by their physician, Medicare is denying these claims until this information is given. Therefore, we are having to get MD orders for all of our Medicare patients at this time so as not to have denied claims. This really is confusing for out patients as Virginia does have Direct Access.
I have added additional questions to this article that will answer your question.
Great article! When we bill CMS for an evaluation, it requires the “Referring Physician” on the claim form. If we do not have an order for services, what is your suggestion? Thank you!
I have added additional questions to this article that will answer your question.
Is there a specific time frame by which the order is considered “valid”?
You would need to defer to your state laws.
What do you do with a patient that does not have orders or a PCP? I have used our chief medical officer to sign our care plans.
You will need to find a physician who is willing to assume responsibility for the Medicare beneficiary receiving outpatient therapy services.