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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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Site Updates

  • New Section Therapists in Private Practice

    28 Feb 2023 10:40 AM | Zachary Edgar (Administrator)

    Medicare guidelines and requirements for therapists in private practice.

    https://therapycomply.com/Medicare/Private-Practice/


  • New section Medicare Certification and Recertification of the POC

    20 Feb 2023 12:33 PM | Zachary Edgar (Administrator)

    Certification and Recertification of the Plan of Care

    Members have full access to the guides below and can contact us with questions regarding and Medicare documentation or billing issue, consider joining today if you need assistance. 

    Certification of the POC

    • What does it mean to have the POC certified?
    • Is a referral or order required under Medicare?
    • What methods of certification are allowed?

    When does the POC need to be Certified? 

    • When is certification consider to be "timely"?
    • What happens if the certification cannot be obtained on time?

    Recertification of the POC

    • When does the POC need to be recertified?
    • Is a recertification the same as a reevaluation?
    • Does Medicare require the patient to visit the physician/NPP before recertification? 

    Who can Certify the POC?

    • Which practitioners are allowed to certify a POC?
    • Which practitioners are not allowed to certify a POC?
    • What does "under the care of the physician" mean?

    Problems Obtaining Certification

    • What should I do if the physician/NPP does not respond to request for signature? 

    Denials Due to Certification Issues

    • Can a denial based on certification be appealed?
    • Examples of when certification issues cause denials

  • Updated Texas Physical Therapy FAQs

    16 Feb 2023 12:28 PM | Zachary Edgar (Administrator)

    See our Texas Physical Therapy FAQs for the updates effective March 1, 2023

  • New Section HIPAA Cybersecurity

    9 Feb 2023 3:52 PM | Zachary Edgar (Administrator)

    We have added a new section to the website to help members better understand the cybersecurity best practices for HIPAA compliance. 

    HIPAA Cybersecurity 

    Webinar: HIPAA for Physical and Occupational Therapists

    March 1st at 12:00 PM CST

    March 2nd at 12:00 PM EST


  • Medicare Progress Report FAQs

    8 Feb 2023 10:50 AM | Zachary Edgar (Administrator)

    See our Medicare Progress Report section for more guidance.

    Who must complete the progress report?

    Information required in progress reports shall be written by a clinician that is, either the physician/NPP who provides or supervises the services, or by the therapist who provides the services and supervises an assistant.

    Who must sign the report?

    The clinician who completed the report must sign and date report.

    It is not required that the referring or supervising physician/NPP sign the progress reports written by a PT, OT or SLP.

    When does the progress report need to be completed?

    The minimum progress report period shall be at least once every ten (10) treatment days. The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, reevaluation or treatment.

    The next treatment day begins the next reporting period. The progress report period requirements are complete when both the elements of the progress report and the clinician’s active participation in treatment have been documented.

    What happens if the report is delayed?

    If the clinician has not written a progress report before the end of the progress reporting period, it shall be written within 7 calendar days after the end of the reporting period. If the clinician did not participate actively in treatment during the progress report period, documentation of the delayed active participation shall be entered in the treatment note as soon as possible. The treatment note shall explain the reason for the clinician’s missed active participation. Also, the treatment note shall document the clinician’s guidance to the assistant or qualified personnel to justify that the skills of a therapist were required during the reporting period. It is not necessary to include in this treatment note any information already recorded in prior treatment notes or progress reports.

    References

    Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services § 220.3

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


  • Plan of Care FAQs

    7 Feb 2023 10:49 AM | Zachary Edgar (Administrator)

    See our Medicare Plan of Care section for more guidance.

    Who can establish a therapy plan of care (POC)?

    Outpatient therapy services shall be furnished under a plan established by:

    • A physician/NPP (consultation with the treating physical therapist, occupational therapist, or speech-language pathologist is recommended. Only a physician may establish a plan of care in a CORF;
    • The physical therapist who will provide the physical therapy services;
    • The occupational therapist who will provide the occupational therapy services; or
    • The speech-language pathologist who will provide the speech-language pathology services.

    Who must sign the POC?

    The person who established the plan must sign and date the plan.  The physician/NPP must also certify the plan by signing and dating it.

    See Certification for more information.

    Can treatment begin before a POC has been established?

    Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who establishes the plan. Payment for services provided before a plan is established may be denied.

    What must be included in the POC?

    The plan of care shall contain, at minimum:

    • Diagnoses;
    • Long term treatment goals; and
    • Type, amount, duration and frequency of therapy services.

    References

    Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services §220.1.2

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


  • Medicare Evaluations/Reevaluations FAQs

    6 Feb 2023 10:48 AM | Zachary Edgar (Administrator)

    See our Medicare Evaluations and Medicare Re-evaluations sections for more detailed guidance.

    Who can perform a therapy evaluation?

    Only a clinician may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care.

    A clinician means either a physician or a physical, occupational, or speech therapist.

    When does an evaluation need to be performed?

    An evaluation must be completed prior to beginning of treatment.

    Can an evaluation and treatment be performed on the same visit?

    Yes. Once the evaluation has been completed, the therapist may start treatment.

    What must be included in the evaluation?

    A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated.

    Results of one of the following four measurement instruments are recommended, but not required:

    • National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association
    • Patient Inquiry by Focus On Therapeutic Outcomes, Inc. (FOTO)
    • Activity Measure – Post Acute Care (AM-PAC)
    • OPTIMAL by Cedaron through the American Physical Therapy Association

    Documentation supporting illness severity or complexity.

    Documentation supporting medical care prior to the current episode.

    Documentation required to indicate beneficiary health related to quality of life.

    Documentation required to indicate beneficiary social support.

    Documentation required to indicate objective, measurable beneficiary physical function.

    References

    Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services §220.3

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

    Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing: A52773

    Outpatient Physical and Occupational Therapy Services: L34049


  • Medicare Certification FAQs

    3 Feb 2023 10:46 AM | Zachary Edgar (Administrator)

    See our Medicare Certification/Recertification section for more guidance.

    What does Medicare require for a certification?

    Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.

    The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of the certification requirements for the duration of the plan of care, or ninety (90) calendar days from the date of the initial treatment, whichever is less. The initial treatment includes the evaluation that resulted in the plan.

    When does the POC need to be certified?

    The provider or supplier (e.g., facility, physician/NPP, or therapist) should obtain certification as soon as possible after the plan of care is established, unless the requirements of delayed certification are met. “As soon as possible” means that the physician/NPP shall certify the initial plan as soon as it is obtained, or within thirty (30) days of 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 (including evaluation).

    Can the certification be done verbally?

    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.

    When is recertification required?

    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.

    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


  • Medicare Orders/Referrals FAQs

    2 Feb 2023 10:45 AM | Zachary Edgar (Administrator)

    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


  • Updated Oklahoma PT FAQs

    1 Feb 2023 1:54 PM | Zachary Edgar (Administrator)

    Added: Scope of practice, continuing education, telehealth, referrals, and ethical/unprofessional conduct.

    Oklahoma PT FAQs

About Me

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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