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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

    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

  • Criteria for Coverage FAQs

    1 Feb 2023 10:44 AM | Zachary Edgar (Administrator)

    See our Outpatient Therapy section for more information on medical necessity.

    What conditions are required to furnish outpatient therapy for Medicare patients?

    The following conditions apply:

    • Services are or were required because the individual needed therapy services;
    • A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP;
    • Services are or were furnished while the individual is or was under the care of a physician; and
    • Claims submitted for outpatient PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care.

    In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above conditions are met.

    How do I demonstrate that the patient needs therapy services?

    The evaluation must include the patient’s particular medical condition that requires skilled therapy.  The plan of care must show that the services are at a level of complexity and sophistication, or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist.

    See Medical Necessity for more information.

    How do I show that the plan is periodically reviewed by a physician/NPP?

    Medicare requires that the plan of care be recertified by the physician/NPP every 90 days.  Recertification is also required if the long term goals in the plan of care are changed.

    See Certification and Recertification for more information.

    How can I document that the patient is or was under the care of a physician?

    Specific documentation that demonstrates that the patient is/was under the care of a physician is not necessary.  Physician certification of the plan of care is the only requirement.   

    Unless there is reason to believe the plan was not signed appropriately, or it is not timely, no further evidence that the patient was under the care of a physician/NPP and that the patient needed the care is required.

    References

    Medicare Benefit Policy Manual Ch. 15 § 220.1

    Medicare Benefit Policy Manual Ch. 15 § 220.1.1


  • Added new OSHA and safety policies and procedures

    15 Dec 2022 11:52 AM | Zachary Edgar (Administrator)

    Employee safety policies and procedures specific to therapy practices.  Members have full access to the guidance documents below and can email us with questions regarding workplace safety and practice specific policies. 

    OSHA Material

    • Blood Bourne Pathogens P&P (Required for Dry Needling)
    • Work-Related Musculoskeletal Disorders
    • Equipment Hazards
    • Slips/Trips/Falls

    Therapy Safety Policies

    • Infection Control Guidelines
    • Universal Precautions
    • Fingernails
    • General Safety Policies
    • General Medical Therapy Equipment
    • Equipment Maintenance
    • Equipment Cleaning/Sterilization
    • Electrically Energized Equipment
    • Patient Transport Equipment
    • Bandaging and Taping
    • Cold Packs
    • Contrast Baths
    • Electrical Muscle Stimulation
    • Heat Packs
    • Iontophoresis
    • Paraffin Bath
    • Skin Care Protocol
    • Transcutaneous Electrical Nerve Stimulation
    • Ultrasound Contact Technique via Gel or Gel Pak
    • Ultrasound Underwater Technique


  • New Guides Added to Medicare Billing and Coding

    23 Nov 2022 3:34 PM | Zachary Edgar (Administrator)


  • Medicare Coverage of Nerve Conduction and Electromyography

    31 Oct 2022 1:59 PM | Zachary Edgar (Administrator)

    Medicare Coverage of Nerve Conduction and Electromyography

  • Medicare Coverage of Biofeedback

    31 Oct 2022 1:57 PM | Zachary Edgar (Administrator)

    Added guidance for Medicare coverage of Biofeedback. 

  • NCCI Edits for Q4 of 2022 have been added

    20 Sep 2022 11:31 AM | Zachary Edgar (Administrator)

    See the NCCI page for the October 2022 NCCI edits for PT, OT, and SLP services.

  • Texas Occupational Therapy FAQs

    22 Aug 2022 3:56 PM | Zachary Edgar (Administrator)

    We have updated our Texas OT Compliance FAQs.

  • Massachusetts PT Compliance FAQs

    22 Aug 2022 12:38 PM | Zachary Edgar (Administrator)

    The Massachusetts Physical Therapy FAQs have been updated.

About Me

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

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