Medicare ADVISOR Q&A

30-day Certification and Recertification

Question: Under Part A in the SNF setting, what is the Medicare guideline regarding the 30-day certification/recertification? If we established a plan of care in our PT/OT evaluation, do we still need to write a clarification order in a separate form to be signed by the physician, if the physician will also sign the evaluation? We are even asked to write extension order for the original clarification order if service continues beyond the amount of time we wrote in the clarification order. I just feel that we are doing unnecessary and redundant paperwork. Is the guideline for Part B the same?

Answer: Under Part A in SNF, there are NO certification/recertification requirements for individual services (PT, OT and Speech). That was a Part B ONLY requirement that, for some reason, became assimilated into SNF Part A. The facility is responsible for obtaining certification and recertification for the overall coverage of Part A skilled care in the facility. This should be done on a time frame of the initial certification covering first 14 days, then recertification by that 14th day and then every 30 days after that.

There is no requirement that the physician signs the actual POT; this requirement was abolished several years ago. Now the regulation reads "POT must be approved by the physician after any needed consultation with the therapist." (IOM Manual Pub: 100-02, Chapter 8). This requirement can be met in several different ways: 1) by a comment in the MD notes identifying that the POT has been reviewed; 2) by the actual signing of the plan; or 3) by a "clarification order" if the "clarification order" contains all of the information required of a plan of treatment.

To reiterate what we have mentioned several times, a "clarification order" has no regulatory basis. Previously its purpose was to ensure that the orders for therapy were accurately entered on to the physician's order for all of the skilled care required by the patient in an SNF.

As to writing an extension order, if the timeframe established in the initial evaluation is exceeded, that is totally appropriate. It is in fact, not a "clarification" but a telephone order to obtain permission to continue treatment under the present plan, because the goals have not been met in the predicted timeframe.

When determining the duration of the treatment plan, it should always be for the actual time the therapist believes it will take to achieve the long term goals (for Part A, the time it will take to safely transition the patient to the next, less expensive, level of care (HHA or Part B services). Sometimes our estimate is incorrect or unforeseen circumstances occur and we need to extend services.

As for Part B, the certification/recertification regulations have changed as of January 1, 2008. The period has been extended from 30 days to 90 days. Again, the duration should be the length of time the therapist expects it to take to achieve the final outcome goals.

Pauline M. Franko, PT is owner of Encompass Consulting & Education, LLC; a consulting and education company specializing in Medicare Compliance and Training, based in Tamarac, FL. The company's "Direction on Demand" service specializes in providing the rehabilitation professional with a clear, easy way to understand how to provide Medicare compliant services to their patients in the SNF and Outpatient settings. As an associate in Comprehensive Medicare Consultants, LLC, she is responsible for assisting with and directing compliance programs to Rehab Agencies. Danna Mullins is an associate and lecturer with Encompass. You may contact the authors through the Encompass website at or by phone at 954-720-4087.

Medicare Advisor Archives

I am a physical therapist new to working in a SNF and would like some general clarification as to when recertifications are required during a patient being on program. Also when is a progress note required? Can one replace the other? Medicare A and B are different in terms of this? Where can I find information on these as well? I am having some trouble finding information on this. Thanks.

Jessie ,  Physical TherapistJanuary 05, 2011

I wanted some clarification on change in Medicare policy regarding re-certification from 30 to 90 days. I understand that CMS published the change in late fall of 2007 and it is in Federal Register. However, there has not been a Change Request Transmittal that I know of which has been sent out by CMS yet. Aren't we getting ahead of oursleves in this matter? Most of the time, they would accept changes retroactivley to the date that it was published but from what I know, any FI could still require more strigent guidelines than what is expectd/required by CMS. We ran into this when CMS published that one did not need a MD order to initiate therapy as long as plan of care was certified by the MD within the 30-days. Our FI still requires us to have an order to initiate therapy and luckily that is how we had continued and are still making sure aobut the initial orders. Your comments would be appreciated.

Thank you,

Priti Shah

Priti Shah,  Director of Rehab,  N. Adams Regional HospitalMarch 25, 2008
N. Adams, MA

Although the assessment reference date for an assessment can be any day in the "window," I am uncomfortable with the practice of facilities always using day 11 for the 14 day MDS, then day 21 for the 30 day MDS and day 50 for the 60 day MDS. Often the treatment minutes then decrease between the assessment dates and increase for the next assessment. Is there any CMS based regulation that addresses using an early ARD rather than the regular dates of 14, 29, 59, 89?

Curtis Hoagland,  PT / DOR,  SNFMarch 24, 2008


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