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Criteria for Coverage FAQs

1 Feb 2023 10:44 AM | Zachary Edgar (Administrator)

See our Outpatient Therapy section for more information on medical necessity.

What conditions are required to furnish outpatient therapy for Medicare patients?

The following conditions apply:

  • Services are or were required because the individual needed therapy services;
  • A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP;
  • Services are or were furnished while the individual is or was under the care of a physician; and
  • Claims submitted for outpatient PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care.

In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above conditions are met.

How do I demonstrate that the patient needs therapy services?

The evaluation must include the patient’s particular medical condition that requires skilled therapy.  The plan of care must show that the services are at a level of complexity and sophistication, or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist, or in the case of physical therapy and occupational therapy by or under the supervision of a therapist.

See Medical Necessity for more information.

How do I show that the plan is periodically reviewed by a physician/NPP?

Medicare requires that the plan of care be recertified by the physician/NPP every 90 days.  Recertification is also required if the long term goals in the plan of care are changed.

See Certification and Recertification for more information.

How can I document that the patient is or was under the care of a physician?

Specific documentation that demonstrates that the patient is/was under the care of a physician is not necessary.  Physician certification of the plan of care is the only requirement.   

Unless there is reason to believe the plan was not signed appropriately, or it is not timely, no further evidence that the patient was under the care of a physician/NPP and that the patient needed the care is required.

References

Medicare Benefit Policy Manual Ch. 15 § 220.1

Medicare Benefit Policy Manual Ch. 15 § 220.1.1


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