Signature Move: Medicare's Certification Requirements for Therapy Plans of Care

Oh, CMS. If only you made your wishes clear, there’d be a lot less confusion—and fewer claim denials—in the world of health care. Unfortunately, that’s just not the case, which is why WebPT devotes a solid quarter every year to educating rehab therapists on the nuances of compliance. And we haven’t come close to running out of relevant topics yet. Today, we’re clarifying some important aspects of Medicare certification requirements for physical therapy care plans. Have questions about obtaining signed POCs for your Medicare patients? You’ve come to the right place. (Although it’s important to note that some state practice acts have different referral requirements—and providers must adhere to the strictest applicable rule. You can learn more about the direct access laws in your state on our blog.)

Can I treat a Medicare patient without a referral?

In most cases, Medicare beneficiaries may seek physical therapy services without first seeing a physician or obtaining a referral (thank you, direct access). In other words, a therapy provider may perform, and bill for, an initial evaluation to determine whether therapeutic intervention is medically necessary—and he or she may do so without involving a physician or other approved non-physician provider (NPP). However, according to compliance expert Tom Ambury—in a comment he left on this blog post—once a therapist determines that therapy is medically necessary for a particular patient, then Medicare requires that patient to be “under the active care of a physician/NPP.” To remain in compliance with this condition of payment, a therapist must obtain a signed plan of care certification within 30 days of a Medicare patient’s initial therapy visit. While Medicare doesn’t require that patients pay a visit to the certifying physician or NPP, some physicians or NPPs may require an office visit before they’ll sign the POC.

According to this California Physical Therapy resource, “Medicare does not require certification of the plan of care before treatment is initiated,” which means providers may decide to begin treatment before obtaining the necessary certification. But, in a comment on the same blog post, WebPT’s Brooke Andrus cautions therapists to do so only if they’re confident they can secure the certification within a month. Otherwise, Ambury says, “the plan is considered ‘delayed,’ and additional documentation is required to explain why it took more than 30 days to get certified and...the reasonable attempts [that were] made to get the plan certified.” That sounds like a whole lot of work that most therapists would prefer to avoid.

How do I ensure I get a signed plan of care (POC)?

Complete your POC.

Therapists must develop a written plan of care for every Medicare patient—and that plan must, at a minimum, include:

• diagnoses;
• long-term treatment goals; and
• the type, quantity, duration, and frequency of therapy services.

Make the request ASAP.

We know you’re busy and that you’ve got a lot on your plate, but procrastinating on POC certification may not end well for you—or your patients. According to Ambury, it’s never a good idea to wait until the last minute to request a POC certification. Quite simply, “if the conditions of payment are not met, Medicare will not pay for the services.” Furthermore, submitting a claim to Medicare without a certified POC on file is a big no-no that could increase your risk for an audit. “Remember, when claims are submitted to Medicare (or any other insurance), [you are] attesting the information on the claim is accurate and you have the documentation to support it,” Ambury wrote.

Develop relationships with physicians.

According to Andrus, “relationships are crucial.” Networking with physicians can help you not only increase referrals, but also streamline your processes with current patients, because, as we wrote in this FAQ doc, “the certifying provider doesn’t necessarily have to be the patient’s regular physician.” Per CMS, the certifying provider can be “a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only).” However, please note that “chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care."

Over time, Andrus says, “it will become easier to get the certifications you need, because you’ll have earned the trust and respect of the physicians in your professional network.”

How do I ensure I get paid?

Get a real or electronic signature—not a stamp.

As we explained in the same FAQ document, “When a physician or NPP certifies a plan of care, he or she must sign and date it.” While stamped signatures are not allowed, electronic signatures are. Additionally, “if the physician or NPP gives verbal certification, he or she must also provide a signature within 14 days of that verbal notice.”

Recertify the POC within 90 days.

Medicare requires that therapists recertify the POC within 90 days of the initial treatment or if the patient’s condition changes in such a way that the therapist must revise long-term goals—whichever occurs first.

Include the certifying party’s NPI on the claim.

As WebPT’s Charlotte Bohnett explains in this article, therapists must include the certifying provider’s name and NPI number in the ordering/referring physician field on the claim form. If that information is missing—or entered incorrectly—Medicare will deny the claim.

Looking for a plan of care easy button? If you’re a WebPT Member, WebPT’s Plan of Care Report will show you which plans of care are still pending certification as well as remind you to complete your recertification before time’s up. You can learn more about using the POC report here.

Not a WebPT Member? Request a demo now to see how we simplify plans of care and help you get paid.

Lastly, if you have specific questions regarding Medicare’s certification requirements that we haven’t answered above, send them our way in the comment section below. We’ll do our best to help you find the answer.