Does Medicare Require an Order for Outpatient Therapy Services

October 7, 2016
Rick Gawenda

Does the Medicare program require an order from a physician or non-physician practitioner in order for a Medicare beneficiary to have an outpatient physical, occupational and/or speech therapy evaluation? The answer is two-fold dependent upon your practice setting.

Lets begin with the Centers for Medicare and Medicaid Services (CMS) outpatient therapy rules and regulations. According to CMS Publication

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  1. one of my staff recently attended a conference where the speaker (who has also been an auditor) stated that if the patient is discharged prior to the plan of care’s recommendation that the provider must approve. Example. patient has signed POC for 2x/week for 4 weeks. Patient reaches all goals by 3 weeks and therapist discharges. per the auditor, the provider has to approve that since we discharged before the 4 weeks on the POC. This is not reasonable as the therapist should be able to clinically determine if patient has met goals. However, with that being said, I would image the signed discharge summary should suffice for provider approval – correct?

    1. Medicare and other insurance companies do not have this requirement. I would ask the speaker for their written reference as it relates to therapy services.

      1. thanks Rick. I will definitely do that. I did not think any requirement like this existed either. appreciate all your help.

  2. How often do you need a new script form the doctor ? When the progress note is done and the POC for that script is finished, do you need a new script or is the signed progress note enough?

  3. Hi Rick,

    I just wanted to clarify your response above about needing an prescritption for therapy in Ohio. Ohio has Direct Access and we are able to see patients without a prescription. Are you saying if you are in a hospital you are not able to see these patients without an order? If the physician signs our evaluation including long term goals and plan of care would this be considered an order?

    1. I would recommend you read the Conditions of Participation for hospitals under Medicare. You will see an order is required.

  4. Hi Rick,
    So does this mean that an evaluation can be performed/billed without an order or anything signed in order to establish a POC (that would then be signed after the eval and before further intevention)?

    1. Under Medicare Part B therapy rules and regulations, the Medicare program requires a signed and dated plan of care and not an order. You also need to look at the Conditions of Participation based on your facility type and see if an order is required. Whichever is most restrictive is the one you must follow.

  5. Currently we are documenting in Optima for our rehab services, our orders are in point click care. I understand the regulation for certification is not specific to signing the actual paper copy, but rather acknowledging that the provider is in agreement with the therapist’s POT. Or physicians are signing an order and an acknowledgment that they have read and are in agreement with the POT as it resides in Optima. Is this sufficient?

    1. A physician order can be used as a Medicare plan of care (POC) if it contains all of the required elements of a POC. Most likely, it does not since a POC requires long term goals.

  6. Does a signature from a NP or PA on a plan of care for Medicare suffice or does it need to be and MD?