Page 182 - Medicare Benefit Policy Manual

change to the duration of the plan and certify it for the duration the physician/NPP finds
appropriate (up to 90 days). Treatment beyond the duration certified by the
physician/NPP requires that a plan be recertified for the extended duration of treatment.
It is possible that patients will be discharged by the therapist before the end of the
estimated treatment duration because some will improve faster than estimated and/or
some were successfully progressed to an independent home program.

Physicians/NPPs may require that the patient make a physician/NPP visit for an
examination if, in the professional’s judgment, the visit is needed prior to certifying the
plan, or during the planned treatment. Physicians/NPPs should indicate their requirement
for visits, preferably on an order preceding the treatment, or on the plan of care that is
certified. If the physician wishes to restrict the patient’s treatment beyond a certain date
when a visit is required, the physician should certify a plan only until the date of the visit.
After that date, services will not be considered reasonable and necessary due to lack of a
certified plan. Physicians/NPPs should not sign a certification if they require a visit and a
visit was not made. However, 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).

Restrictions on Certification. 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. Chiropractors may not certify or recertify
plans of care for therapy services.

D. Delayed Certification

References: §1835(a) of the Act
42CFR424.11(d)(3)

Certifications are required for each interval of treatment based on the patient’s needs, not
to exceed 90 calendar days from the initial therapy treatment. Certifications are timely
when the initial certification (or certification of a significantly modified plan of care) is
dated within 30 calendar days of the initial treatment under that plan. Recertification is
timely when dated during the duration of the initial plan of care or within 90 calendar
days of the initial treatment under that plan, whichever is less. Delayed certification and
recertification requirements shall be deemed satisfied where, at any later date, a
physician/NPP makes a certification accompanied by a reason for the delay.
Certifications are acceptable without justification for 30 days after they are due. Delayed
certification should include one or more certifications or recertifications on a single
signed and dated document.

Delayed certifications should include any evidence the provider or supplier considers
necessary to justify the delay. For example, a certification may be delayed because the
physician did not sign it, or the original was lost. In the case of a long delayed