Page 181 - Medicare Benefit Policy Manual

or 90 calendar days from the date of the initial treatment, whichever is less. The initial
treatment includes the evaluation that resulted in the plan.

Timing of Initial Certification. 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 30 days of the initial therapy treatment. Since payment may be
denied if a physician does not certify the plan, the therapist should forward the plan to the
physician as soon as it is established. Evidence of diligence in providing the plan to the
physician may be considered by the Medicare contractor during review in the event of a
delayed certification.

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.

Recertification is not required if the duration of the initially certified plan of care is more
than the duration (length) of the entire episode of treatment.

C. Review of Plan and Recertification
Reference: 42CFR424.24(c), 1861(r), 42CFR 410.61(e).

The timing of recertification changed on January 1, 2008. Certifications signed on or
after January 1, 2008, follow the rules in this section. Certifications signed on or prior to
December 31, 2007, follow the rule in effect at that time, which required recertification
every 30 calendar days.

Payment and coverage conditions require that the plan must be reviewed, as often as
necessary but at least whenever it is certified or recertified to complete the certification
requirements. It is not required that the same physician/NPP who participated initially in
recommending or planning the patient’s care certify and/or recertify the plans.

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 90 days after initiation of treatment under that plan, unless they are delayed.

Physician/NPP Options for Certification. A physician/NPP may certify or recertify a
plan for whatever duration of treatment the physician/NPP determines is appropriate, up
to a maximum of 90 calendar days. Many episodes of therapy treatment last less than 30
calendar days. Therefore, it is expected that the physician/NPP should certify a plan that
appropriately estimates the duration of care for the individual, even if it is less than 90
days. If the therapist writes a plan of care for a duration that is more or less than the
duration approved by the physician/NPP, then the physician/NPP would document a