Outpatient Rehabilitation Therapy Certification Changes

Published 01/21/2026

On January 1, 2025, changes were effective in CFR 424.24 which indicate the initial plan of care for outpatient therapy services is not required to be signed (certified) by the medical doctor (MD)/nonphysician practitioner (NPP) if certain criteria are met.

Specifically, paragraph (c) (5) was added which indicates if (1) the plan of treatment is established by a therapist, (2) there is a written order or referral from the individual's MD/NPP in the patient's record, and (3) the therapist has documented evidence that the plan of treatment has been delivered to the MD/NPP within 30 days of completion of the initial evaluation, then the certification does not need to be signed by a MD/NPP. Any recertifications must still be signed. 

424.24 Requirements for medical and other health services furnished by providers under Medicare Part B. 

(5) Treatment plan. If the plan of treatment is established by a physical therapist, occupational therapist, or speech-language pathologist, and there is a written order or referral from the individual's physician, nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS) in the patient's record and the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation, the certification does not need to be signed by a physician, NP, CNS, or PA who has knowledge of the case. If there is no written order or referral from the individual's physician, NP, CNS, or PA, in the patient's record, the therapist must obtain the signature of the physician, NP, PA, or CNS on the plan of treatment in accordance with paragraph (c)(3) of this section. No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services.

According to CMS Medicare Fee-for-Service (FFS) Supplemental Improper Payment Data, insufficient documentation is the primary reason for therapy denials. This is information provided by the CERT (Comprehensive Error Rate Testing) contractor annually, measures improper payments in the Medicare (FFS) program and selects a random sample of Medicare FFS claims for review to determine if they were properly paid under Medicare coverage, coding, and billing rules.

The table below provides common errors identified from these reviews. 

Table 1
Common Errors How to Prevent Denial
Missing certifications, recertifications, or reason for delayed certifications Confirm physician or NPP certified the POC (and recertified it when appropriate) with their signature and date. Delayed certifications require a statement explaining reason for delay.
Missing signature: Physician, NPP, or therapist who developed the POC and established treatment plan date Ensure you add your dated signature and professional identification (for example, PT, OT).
Missing or incomplete POC Create a complete POC that includes diagnoses, long-term goals, type, amount, frequency, and service(s) duration.
Missing significant POC changes: Certifications and recertification(s) Certify a significantly modified POC (physician or NPP signs and dates it).

Missing total time: For timed procedures and total active treatment time

 Clearly document in 15-minute timed codes the total treatment time to support number of units and codes billed for each treatment day; document total active treatment time (including timed and untimed codes) in the patient’s medical record.

Missing or incomplete initial evaluation

 Document initial evaluation with your signature, professional identification (for example, PT, OT) and date you made the initial evaluation. See section 220.3 of the Medicare Benefit Policy Manual, Chapter 15 (PDF) for more information.

Missing or incomplete progress reports

 Progress reports justify medical necessity and require information such as timing (at least once every 10 treatment days) and should include your signature, professional identification, and date (see section 220.3 of Medicare Benefit Policy Manual, Chapter 15 (PDF) for more information.

Missing elements supporting medical necessity

 See Sections 220 and 230 of the Medicare Benefit Policy Manual, Chapter 15 (PDF) for more information.

Note: If Palmetto identifies a potential outpatient therapy Part B claim overpayment within  six years of receiving the overpayment (generally referred to as the “look back period”), the provider must report and return all identified overpayments. See section 1128J(d) of the Social Security Act for more information.

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