Page 183 - Medicare Benefit Policy Manual

certification (over 6 months), the provider or supplier may choose to submit with the
delayed certification some other documentation (e.g., an order, progress notes, telephone
contact, requests for certification or signed statement of a physician/NPP) indicating need
for care and that the patient was under the care of a physician at the time of the treatment.
Such documentation may be requested by the contractor for delayed certifications if it is
required for review.

It is not intended that needed therapy be stopped or denied when certification is delayed.
The delayed certification of otherwise covered services should be accepted unless the
contractor has reason to believe that there was no physician involved in the patient’s care,
or treatment did not meet the patient’s need (and therefore, the certification was signed
inappropriately).

EXAMPLE: Payment should be denied if there is a certification signed 2 years after
treatment by a physician/NPP who has/had no knowledge of the patient when the medical
record also shows e.g., no order, note, physician/NPP attended meeting, correspondence
with a physician/NPP, documentation of discussion of the plan with a physician/NPP,
documentation of sending the plan to any physician/NPP, or other indication that there
was a physician/NPP involved in the case.

EXAMPLE: Payment should not be denied, even when certified 2 years after treatment,
when there is evidence that a physician approved needed treatment, such as an order,
documentation of therapist/physician/NPP discussion of the plan, chart notes, meeting
notes, requests for certification, certifications for intervals before or after the service in
question, or physician/NPP services during which the medical record or the patient’s
history would, in good practice, be reviewed and would indicate therapy treatment is in
progress.

EXAMPLE: Subsequent certifications of plans for continued treatment for the same
condition in the same patient may indicate physician certification of treatment that
occurred between certification dates, even if the signature for one of the plans in the
th
episode is delayed. If a certified plan of care ends March 30 and a new plan of care for
th
continued treatment after March 30 is developed or signed by a therapist on April 15 th
and that plan is subsequently certified, that certification may be considered delayed and
th
acceptable effective from the first treatment date after March 30 for the frequency and
duration as described in the plan. Of course, documentation should continue to indicate
that therapy during the delay is medically necessary, as it would for any treatment. The
certification of the physician/NPP is interpreted as involvement and approval of the
ongoing episode of treatment, including the treatment that preceded the date of the
certification unless the physician/NPP indicates otherwise.

E. Denials Due to Certification

Denial for payment that is based on absence of certification is a technical denial, which
means a statutory requirement has not been met. Certification is a statutory requirement
in SSA 1835(a)(2)- (‘periodic review” of the plan).