Medicare Part B Certifications and Recertifications

July 2, 2018
Rick Gawenda

I receive many questions regarding Medicare Part B certifications and recertifications as they pertain to outpatient physical, occupational and speech therapy services. In this article, I will answer the following questions:

1. How long is a certification and recertification valid for under Medicare Part B outpatient therapy services?
2. How soon must a plan of care be signed by a physician or NPP to be considered timely under Medicare Part B rules and
3. What is delayed certification and recertification? 
4. What are some possible justifications to support delayed certification or recertification?
5. If I only do an evaluation on a Medicare beneficiary under Part B and discharge them as they do not required continued
therapy, must I have the plan of care signed and dated by the physician/non-physician practitioner?
6. If I evaluate and treat a Medicare beneficiary in the emergency department or while under observation status and they do not
get admitted to the hospital (i.e. they get discharged home), must I have the plan of care signed and dated by the physician?
In addition, check out my 2 recent articles on who can certify and recertify for outpatient therapy services. Click HERE to read about dentists and chiropractors certifying and recertifying an outpatient therapy plan of care. Click HERE to see the full list of who can certify and recertify for outpatient therapy services.
Lets begin!
Question #1:
How long is a certification and recertification valid for under Medicare Part B outpatient therapy services?

The content here is for members only log in here or sign up.

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.

Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

  1. A few years ago I read something that said you must try to get the certification signed by the provider for 2 years before you do not get the signature. Looking for validation on this. We currently save all fax confirmations and document all phone calls when trying to get the certification or recertification signed but if we are not able to obtain this within 2 years then we stop trying at that time. Any help on this question. Thank you.

  2. Are there any differences, regarding the time frame of the physician’s signature on the plan of care, between professional and institutional?

  3. If the Dr signs a POC for example 2x/week for 5 weeks, what happens if the patient misses a week or 2 due to vacation or illness?

    1. If you stated a duration of 5 weeks, a Medicare contractor could state you would need a recertification after 5 weeks even if the patient did not have their 10 visits yet ( 2 times per week times 5 weeks).

  4. How long is an initial doctor’s signed prescription good for? If a patient is unavailable to be seen for a few weeks and finally calls to schedule but the signed order is from 6 weeks ago, is that prescription still valid? Or do we need to get a fresh signed order from the MD?

    1. If there are any restrictions on how long a physician order is valid for, you would need to check your state practice act. state Administrative rules and with the insurance carrier.

  5. what if the ordering physician is no longer in practice, and there is no one to sign the POC?

  6. In a recent e-mail from CMS MLN Connects there was a link for a new publication called “Medicare Billing for Outpatient Physical Therapy Fact Sheet — New” and on page 3 it states “Medicare Part B regulations require all covered outpatient PT services be: Certified by a physician or NPP (the provider must sign the POC before treatment starts, except
    for the time allowed for transcription)”

    Am I reading this correctly that the PT cannot provide any additional treatment until the POC has in fact been signed? This just doesn’t sound right, can you please provide further explanation on this? And if it is correct, would having a referral/RX from a physician or NPP suffice?

    1. That publication contained many errors and APTA has notified CMS of the errors. I recommend you read and reference CMS Publication 100-02, Chapter 15, Section 220.1.1 – 220.1.3 for the requirements for a plan of care and certification/recertification requirements and timely signatures.

  7. What if the POC ends 2 days prior to the final visit the patient is seen – is there any grace period, or do you need to get a new POC signed to cover that last visit?

  8. We file on UB04 and have never filed medicare as a secondary but going to give it a try. Do we still have to get a care plan signed if we are filing medicare as a secondary? Thank You

  9. Does the POC include the number of visits or just the time frame? For example of the POC = 2 times a week for 6 weeks, what happens if we see the patient for 13 or 14 visits within the 6 weeks rather than the 12 carved out in the POC?

    1. 2 times per week would allow for up to 12 visits in the 6 week period. You could not do more than that.

  10. Hi Rick,
    I just wanted to make sure I understand this correctly…if a therapist establishes a POC for the max time frame of 90 days (example: 03/01/19 to 06/01/19 but they also state in their POC 2x week for 8 weeks (16 visits); if the patient attends the 16th visit before the POC end date (example: 16th visit lands on 05/05/19), does a recertification need to be signed at this point even though its established thru 06/01/19?
    Thank you!!!

    1. For Medicare Part B, if you establish your plan of care at 2 times per week for 16 treatment sessions, those 16 treatment sessions would need to be completed within 90 calendar days of the initial visit. There is no need or requirement to put a date range for the plan of care (i.e. 03/01/19 – 06/01/19)

  11. But if the patient continues to a 17th visit or more, still within those 90 days, a recert would need to be signed? Is that correct?

  12. We are currently going through our TPE audit, Round 2. One of our reviewers stated that the recertification had to be signed within 30 days and on day 31 a delayed justification is required. I can not find that in the CMS manual under 220.1.3. Is there a reference in the manual that explains the delayed certification after day 30 on the recert?

      1. Here is the exact wording: Certifications are acceptable without justification for 30 days after they are due.
        This includes the recertification.

  13. For hospitals where Medicare patients are seen in the ED/Observation and post procedure recovery status and billed under an ED/Observation bundle or a Comprehensive APC payment rather than billed separately as part B outpatient therapy (both evaluation and treatment is documented/performed), does the Plan of Care that is developed for these patients still need to be certified by the physician?

    1. If not billing separately for outpatient therapy, then the plan of care for Medicare Part B would not be required.