Posted on December 7, 2022

See our Full Guide on Certification and Recertification of the Therapy POC

What does it mean to have the plan of care certified?

Certification is the physician’s/non-physician practitioner’s (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.

Claims submitted for outpatient (and CORF) PT, OT and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT/OT/SLP plan of care. 

Do I need an order/prescription/referral from a physician/NPP?

No.  When the physician/NPP signs and dates the POC, they certify that:

• Therapy services are required for the patient;
• The POC has been established and reviewed by the physician/NPP; and
• Services are or were furnished while the individual is or was under the care of the physician/NPP.

Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.

Who must certify the POC?

The physician/NPP who is treating the patient.

Physician with respect to outpatient rehabilitation therapy services means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only).

NPP means physician assistants, clinical nurse specialists, and nurse practitioners, who may, if state and local laws permit it, and when appropriate rules are followed, provide, certify or supervise therapy services.

When does the POC need to be certified?

Certifications are required for each interval of treatment based on the patient’s needs, not to exceed ninety (90) calendar days from the initial therapy treatment.

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 thirty (30) days following the first day of treatment.

What happens if I can’t get the plan certified within ninety (90) days?

Delayed certifications are acceptable. 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 thirty (30) days after they are due.

Are verbal certifications acceptable?

If the order to certify is verbal, it must be followed within fourteen (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.

When does the POC need to be recertified?

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 ninety (90) days after initiation of treatment under that plan, unless they are delayed.

What happens if the recertification is delayed?

Like the initial certification, if the recertification is delayed then you must produce evidence that the physician/NPP approves the recertification of the POC and that continued therapy is justified.

Reference

Medicare Benefit Manual Ch. 15 § 220.1.3