When Do Physical Therapists Need to Obtain Physician Signatures?

In this day and age, a signature is valuable currency. It’s the key to making a dream house your home—the final step between “fiancé” and “newlywed.” From the right artist or celebrity, a signature can turn an ordinary object into a valuable collector’s item. Likewise, signatures are very important in the physical therapy world. After all, documentation without a PT’s signature is hardly documentation at all.

But when it comes to obtaining a physician’s signature on physical therapy documentation, the rules can get a little blurry. For that reason, we’ve compiled the following common scenarios when a physical therapist may—or may not—need a physician’s signature:

1. Certifications and Recertifications

The Short Answer:

Yes, you must obtain a physician’s signature on certifications and recertifications.

The Long Answer:

Of all the questions we receive from WebPT Blog readers, Medicare certification queries are a frequent flyer. Fortunately, the Centers for Medicare and Medicaid Services (CMS) has laid out some pretty clear guidelines when it comes to proper certification procedures. According to this CMS resource, a “certification is the physician’s/nonphysician 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.” Physical therapists must create a plan of care (POC) during a Medicare patient’s initial evaluation. The PT must then ship either the POC or evaluative note to the physician, who must then sign and return the document within 30 days of the day the plan was established.

What if the signature is delayed?

Of course, obtaining a signed plan of care is often easier said than done. Fortunately, Medicare is well aware of this and allows PTs to obtain a delayed certification as long as they can prove the holdup was on the physician’s end. (Pro tip: This is why it’s a good idea to use a documentation platform like WebPT, which tracks the time and date your POCs were sent to the physician for signing!)

2. Evaluations and Re-Evaluations

The Short Answer:

No, you typically do not need a physician’s signature on evaluative notes.

The Long Answer:

Generally speaking, Medicare does not require PTs to obtain a physician’s signature on an eval or re-eval. The exception to this rule would be if you use the evaluative note to certify the plan of care dates, as outlined in 220.1.3 Item A of the Medicare Benefit Policy Manual - Chapter 15. In this case, you would submit the evaluative note to the physician or NPP for signature just as you would with a plan of care document.

Some physicians may request a copy of the evaluative note for their own reference. Keep in mind that this is a personal request—not a Medicare requirement.

3. Progress Reports

The Short Answer:

No, you typically do not need a physician’s signature on a progress report.

The Long Answer:

According to CMS, a “Progress Report written by a therapist does not require a physician/NPP signature when written as a stand-alone document.” That said, similar to an evaluative note, you can send the progress report to the physician for re-certification in place of a plan of care document as long as it meets the documentation requirements listed in the Medicare Benefit Policy Manual.

4. Discharge Summaries

The Short Answer:

No, you typically do not need a physician’s signature on a discharge summary.

The Long Answer:

In Medicare’s eyes, a discharge summary is functionally the same as a standalone progress note. And as we discussed above, Medicare does not require a physician’s signature on a standalone progress note (i.e., a progress note that does not also serve as a plan of care).

One other thing to note: Much like an evaluation, the patient’s physician may request a copy of the completed discharge summary. However, this is not a Medicare requirement.

5. Goal Updates

The Short Answer:
Yes, you need to obtain a physician’s or NPP’s signature when updating long-term goals—but not short-term goals.

The Long Answer: 

In the above-referenced CMS document, Medicare states that you do not need to obtain a physician’s signature when updating short-term goals or procedures and modalities based on “a normal progression in the patient’s disease or condition.” This guidance also applies to any “adjustments to the plan due to lack of expected response to the planned intervention” as long as the goals remain unchanged. However, if the patient’s condition changes to the point that you must revise long-term goals, you must send a new plan of care document, progress report, or re-evaluation to the physician for signature.

6. Referrals

The Short Answer:

If your state or the patient’s insurance requires a physician’s referral, then yes, you must obtain a signature.

The Long Answer:

Depending on where you’re located or which insurance policy your patient uses, you may need to obtain a signed physician’s referral at some point during the episode of care. If your state’s direct access laws conflict with the insurance’s referral rules, you’ll need to follow the more stringent guidelines.

For example, if you’re located in Arizona and the patient has a commercial insurance policy that does not require a physician’s order, then you can evaluate and treat the patient without ever obtaining a physician referral. That’s because Arizona allows patients total, unrestricted access to physical therapy services. However, if the insurance policy requires a physician’s referral, you would still need to obtain that referral before treatment begins—despite Arizona’s unrestricted direct access laws.

Now, if you’re located in a state like Indiana—which allows PTs to treat patients without a referral for up to 45 days—and a patient has an insurance policy that does not require a referral for PT, then you would still need to obtain a physician’s referral if you wish to treat the patient beyond the initial 45-day period.

Put simply, if either your state or the patient’s insurance policy requires a physician’s referral, then you must obtain one—and it must be signed by the physician, of course.   

7. Services Billed Incident to a Physician

The Short Answer:

No, you do not need a physician’s signature when billing incident to a physician.

The Long Answer:

According to PT compliance expert Rick Gawenda, PT, “CMS does not require the physician to cosign the notes of the PT when billing incident-to.” That said, you’ll still need to comply with the plan of care signature requirements that Medicare usually requires for Part B services.

A signature is a powerful thing—especially on physical therapy documentation. Got any questions about signature requirements? Let us know in the comment section below!