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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medicare Orders/Referrals FAQs

See Outpatient Therapy Services and Certification/Recertification for more details. 

Does Medicare require an order or referral?

No. Although there is no Medicare requirement for an order, an order provides evidence that the patient both needs therapy services and is under the care of a physician. The certification requirements are met when the physician certifies the plan of care, this means the physician/NPP has signed and dated the plan of care.

If the signed order includes a plan of care, no further certification of the plan is required. 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.

When does the POC have to signed by the physician/NPP?

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.  

Does Medicare require that the patient visit the physician?

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).

Which providers can certify a POC?

Physicians and non-physician practitioners such as nurse practitioners and physician assistants.

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.

Which providers cannot certify a POC?

Chiropractors may not certify or recertify plans of care for therapy services.

The CORF services benefit does not recognize an NPP for orders and certification.

References

Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services § 220.1.3

Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067

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