Medicare General Information, Eligibility, 
and Entitlement 
Chapter 4 - Physician Certification and Recertification 
of Services 
 
Table of Contents 
(Rev. 10757, Issued: 05-11-21) 
 
Transmittals for Chapter 4 
 
10 - Certification and Recertification by Physicians for Hospital Services - General 
10.1 - Failure to Certify or Recertify for Hospital Services 
10.2 - Who May Sign Certification or Recertification 
10.3 - Certification for Hospital Admissions for Dental Services 
10.4 - Inpatient Hospital Services Certification and Recertification 
10.5 - Selection by Hospital of Format and Method for Obtaining Statement 
10.6 - Criteria for Continued Inpatient Hospital Stay 
10.7 - Utilization Review (UR) in Lieu of Separate Recertification Statement 
10.8 - Timing of Certifications and Recertifications 
10.8.1 - Admissions on or after January 1, 1970 for Non-PPS Hospitals 
10.8.2 - Patients Discharged During Hospital Fiscal Years Beginning on or 
after October 1, 1983 Under PPS 
10.9 - Inpatient Psychiatric Facility Services Certification and Recertification 
10.9.1 - Delayed/Lapsed Certification and Recertification 
20 - Certification for Hospital Services Covered by the Supplementary Medical Insurance 
Program 
20.1 - Delayed Certifications and Recertifications 
20.2 - Timing for Certification and Recertification for A Beneficiary Admitted 
Before Entitlement 
30 - Certification and Recertification by Physicians and Allowed Practitioners for Home 
Health Services 
30.1 - Content of the Physician's Certification 
30.2 - Method and Disposition of Certifications for Home Health Services 
30.3 - Recertifications for Home Health Services 
40 - Certification and Recertification by Physicians for Extended Care Services 
40.1 - Who May Sign the Certification or Recertification for Extended Care 
Services 
40.2 - Certification for Extended Care Services  40.3 - Recertifications for Extended Care Services 
40.4 - Timing of Recertifications for Extended Care Services 
40.5 - Delayed Certifications and Recertifications for Extended Care Services 
40.6 - Disposition of Certification and Recertifications for Extended Care 
Services 
50 - Physician's Certification and Recertification for Outpatient Physical Therapy, 
Occupational Therapy and Speech-Language Pathology 
60 - Certification and Recertification by Physicians for Hospice Care 
70 - DME Certification 
80 - Summary Table for Certifications/Recertifications  10 - Certification and Recertification by Physicians for Hospital 
Services  General 
(Rev. 1, 09-11-02) 
 
Payments may be made for covered hospital services only if a physician certifies and 
recertifies to the medical necessity for the services at designated intervals of the hospital 
inpatient stay. Appropriate supporting material may be required. The physician 
certification or recertification statement must be based on a current evaluation of the 
patient's condition. 
 
For patients admitted to a general hospital, regardless of whether the patients are under 
PPS, a physician certification is not required at the time of admission for patient services. 
For services continued over a period of time or for a day outlier case (i.e., an 
appropriately admitted case results in an extraordinarily long stay) or for a PPS cost 
outlier case (i.e., an appropriately admitted case results in the expenditure of 
extraordinary resources), a physician must certify or recertify the continued need for the 
services at specified intervals. (See  80 for timing of physician certification and 
recertification.) Psychiatric and tuberculosis hospitals (which are excluded from PPS) are 
required to obtain a physician certification on admission. 
 
Hospitals do not transmit physician certification and recertification statements to the A/B 
MAC (A) or to CMS. The hospital must itself certify on the appropriate billing form that 
the required physician certification and recertification statements have been obtained and 
are on file. The physician certification and recertification statements are retained in the 
hospital's file where they are available for verification if needed. 
 
A hospital must also have available in its files a written description of the procedure it 
adopts on the timing of certifications and recertifications, i.e., the intervals at which the 
necessary certification statements are required and whether review of long stay cases by 
the utilization review committee may serve as an alternative to recertification by a 
physician in the case of the second or subsequent recertification. 
 
10.1 - Failure to Certify or Recertify for Hospital Services 
(Rev. 1, 09-11-02) 
 
If a hospital fails to obtain the required certification or recertification statements in an 
individual case, program payments may not be made in that case. 
 
If the hospital's failure to obtain a certification or recertification is not due to a question 
as to the necessity for the services, but rather to the physician's refusal to certify based on 
other grounds (e.g., he/she objects in principle to the concept of certification and 
recertification), the hospital may not bill the program or the beneficiary for covered items 
or services. The provider agreement precludes the hospital from charging the patient for 
covered items and services. 
 
  10.2 - Who May Sign Certification or Recertification 
(Rev. 1, 09-11-02) 
 
A certification or recertification statement must be signed by the attending physician 
responsible for the case or by another physician who has knowledge of the case and is 
authorized to do so by the attending physician, or by a member of the hospital's medical 
staff with knowledge of the case. 
 
Ordinarily for purposes of certification and recertification, a "physician" must meet the 
definition in Chapter 5, 70 and 70.3. 
 
10.3 - Certification for Hospital Admissions for Dental Services 
(Rev. 1, 09-11-02) 
 
The attending doctor of dental surgery or of dental medicine is authorized to certify that 
the patient's underlying medical condition and clinical status or the severity of the dental 
procedure requires the patient to be admitted to the hospital for the performance of the 
dental procedure; and to recertify the patient's continuing need for hospitalization when 
required.  This applies even if the dental procedure is not covered. 
 
10.4 - Inpatient Hospital Services Certification and Recertification 
(Rev. 1, 09-11-02) 
 
A certification or recertification statement must contain the following information: 
 
  An adequate written record of the reason for either; 
 
  Continued hospitalization of the patient for medical treatment or for 
o
medically required inpatient diagnostic study, or  
 
  Special or unusual services for cost outlier cases for hospitals under 
o
the prospective payment system (PPS); 
 
  The estimated period of time the patient will need to remain in the hospital 
and, for cost outlier cases, the period of time for which the special or unusual 
services will be required; and  
 
  Any plans for posthospital care. 
 
10.5 - Selection by Hospital of Format and Method for Obtaining 
Statement 
(Rev. 1, 09-11-02) 
 
The individual hospital determines the method by which certifications and recertifications 
are to be obtained and the format of the statement.  Thus, the medical and administrative  staffs of each hospital may adopt the form and procedure they find most convenient and 
appropriate. 
 
There is no requirement that the certification or recertification be entered on any specific 
form or handled in any specific way, as long as the approach adopted by the hospital 
permits the A/B MAC (A) to determine that the certification and recertification 
requirements are, in fact, met.  The certification or recertification could, therefore, be 
entered or preprinted on a form the physician already has to sign; or a separate form 
could be used.  If all the required information is included in progress NOTEs, the 
physician's statement could indicate that the individual's medical record contains the 
information required and that continued hospitalization is medically necessary. 
 
10.6 - Criteria for Continued Inpatient Hospital Stay 
(Rev. 94, Issued: 10-16-15, Effective: 11-16-15, Implementation: 11-16-15) 
 
A physician who certifies or recertifies to the need for continued inpatient stay should use 
the same criteria that apply to the hospital's utilization review committee.  These criteria 
include not only medical necessity, but also the availability of out-of-hospital facilities 
and services which will assume continuity of care.  In accordance with the regulations at 
42 CFR 424.13(c), a physician should certify or recertify need for continued 
hospitalization if the physician finds that the patient could receive treatment in a SNF but 
no bed is available in the participating SNF.  Where the basis for the certification or 
recertification is the need for continued inpatient care because of the lack of SNF 
accommodations, the certification or recertification should so state.  The physician is 
expected to continue efforts to place the patient in a participating SNF as soon as the bed 
becomes available.  Coverage of these additional, alternate placement days in the 
hospital can continue until the earliest of the following events occurs: 
 
  A bed becomes available in a participating SNF; 
  The beneficiarys care needs drop below SNF-level; or 
  The beneficiary has exhausted all of the available days of Part A inpatient hospital 
benefits in that benefit period. 
 
10.7 - Utilization Review (UR) in Lieu of Separate Recertification 
Statement 
(Rev. 1, 09-11-02) 
 
For cases not subject to PPS and for PPS day outlier cases, a separate recertification 
statement is not necessary where the requirements for the second or subsequent 
recertification are satisfied by review of a stay of extended duration, pursuant to the 
hospital's UR plan. However, it is necessary to satisfy the certification and recertification 
content standards. It would be sufficient if records of the UR committee show that 
consideration was given to the three items required for certifications and recertifications: 
the reasons for continued hospitalization (e.g., consideration was given to the need for 
special or unusual care in cost outlier status under PPS), estimated time the patient will  need to remain in the hospital (e.g., the time period during which such special or unusual 
care would be needed), and plans for posthospital care. 
 
10.8 - Timing of Certifications and Recertifications 
(Rev. 1, 09-11-02) 
 
The timing of certifications and recertifications is described in the following subsections. 
 
10.8.1 - Admissions On or After January 1, 1970 for Non-PPS Hospitals 
(Rev. 1, 09-11-02) 
 
For services furnished to beneficiaries admitted on or after January 1, 1970, the initial 
certifications are required no later than as of the 12th day of hospitalization. A hospital 
may at its option, provide for the certification to be made earlier, or it may vary the 
timing of the certification within the 12-day period by diagnostic or clinical categories. 
The first recertification is required no later than as of the 18th day of hospitalization. 
Subsequent recertifications must be made at intervals established by the UR committee 
(on a case-by-case basis), but in no event may the interval between recertifications 
exceed 30 days. 
 
The UR committee will be reviewing long-stay cases and may be in the best position to 
decide when subsequent recertifications are needed. 
 
A hospital can, if it wishes, coordinate its physician recertifications with the process of 
review by the UR committee of longstay cases not subject to PPS, and for PPS day-
outlier cases. At the option of the hospital, review of a stay of extended duration under 
the hospital's utilization review plan may take the place of the second and any subsequent 
physician recertifications. (Such review may be the initial review, or a second or 
subsequent review of an extended case by the UR committee.) 
 
Where review of an extended stay case by the UR committee is deemed to take the place 
of a physician recertification, it would be possible for the recertification to be made later 
than the specified day, because the review of an extended duration case may be made at 
any time within the 7-day period following the last day of the period of extended duration 
defined in the utilization review plan. Such a recertification will be treated as a delayed 
recertification; however, no explanation for the normal delay is required. 
 
10.8.2 - Patients Discharged During Hospital Fiscal Years Beginning On 
or After October 1, 1983 Under PPS 
(Rev. 1, 09-11-02) 
 
For cases subject to the prospective payment system (PPS), certification is not required at 
the time of admission for inpatient services. The admission is reviewed by a hospital 
review organization upon discharge of the patient. For outlier cases certification is 
required as follows: 
    For day-outlier cases (now discontinued), certification was required no later 
than 1 day after the hospital reasonably assumes that the case meets the 
established outlier criteria, or no later than 20 days into the hospital stay, 
whichever is earlier. The first and subsequent recertifications are required at 
intervals established by the utilization review committee, on a case-by-case 
basis if it so chooses, but not less than every 30 days. 
 
  For cost-outlier cases, if possible, certification must be made before the 
hospital incurs cost for which it will seek cost outlier payment. However, 
certification is required no later than the date on which the hospital requests 
cost outlier payment or 20 days into the hospital stay, whichever is earlier. For 
cost-outlier cases, the first and subsequent recertifications are required at 
intervals established by the UR committee, on a case-by-case basis if it 
chooses. 
 
As previously stated the UR committee will be reviewing long-stay cases and may be in 
the best position to decide when subsequent recertifications are needed. Review by the 
UR committee used in place of recertification for PPS day outlier cases is considered 
timely if performed within 7 days after the physician recertification would have been 
required. 
 
10.9 - Inpatient Psychiatric Facility Services Certification and 
Recertification 
(Rev. 98, Issued: 05-13-16, Effective: 08-15-16, Implementation: 08-15-16) 
 
The requirements for physician certification and recertification for inpatient psychiatric 
facility services are similar to the requirements for certification and recertification for 
inpatient hospital services.  However, there is an additional certification requirement.  In 
accordance with 42 CFR 424.14, all IPFs (distinct part units of acute care hospitals, 
CAHs, and psychiatric hospitals) are required to meet the following certification and 
recertification requirements. 
 
At the time of admission or as soon thereafter as is reasonable and practicable, a 
physician (the admitting physician or a medical staff member with knowledge of the 
case) must certify the medical necessity for inpatient psychiatric hospital services.  The 
first recertification is required as of the 12th day of hospitalization.  Subsequent 
recertifications will be required at intervals established by the hospitals utilization 
review committee (on a case-by-case basis), but no less frequently than every 30 days. 
 
There is also a difference in the content of the certification and recertification.  In 
certification the physician is required to document that the inpatient psychiatric facility 
admission was medically necessary for either:  (1) treatment which could reasonably be 
expected to improve the patient's condition, or (2) diagnostic study. 
 
The physician's recertification should satisfy all of the requirements noted below: 
  1.  That inpatient psychiatric hospital services furnished since the previous 
certification or recertification were, and continue to be, medically necessary 
for either: 
 
a.  Treatment which could reasonably be expected to improve the patient's 
condition; or, 
 
b.   Diagnostic study; 
 
2.  The hospital records indicate that the services furnished were either intensive 
treatment services, admission and related services necessary for diagnostic 
study, or equivalent services, and 
 
3.  Effective July 1, 2006, physicians will also be required to recertify that the 
patient continues to need, on a daily basis, active treatment furnished directly 
by or requiring the supervision of inpatient psychiatric facility personnel. 
 
The format of all certifications and recertifications and the method by which they are 
obtained is determined by the individual facility.  No specific procedures or forms are 
required.  The provider may adopt any method that permits verification of all the IPFs 
requirements to continue treatment.  For example, the recertification may be entered on 
provider generated forms, in progress notes, or in the records (relating to the stay in 
question) and must be signed by a physician. 
 
Claim denials may not be made for failure to use a certification or recertification form or 
failure to use particular language or format, provided that the medical record 
demonstrates that the content requirements given at Pub. 100-02, Medicare Benefit 
Policy Manual, Chapter 2, 30.2.1 are met. 
 
For convenience, the period covered by the physician's certification and recertification is 
referred to a period during which the patient was receiving active treatment.  If the patient 
remains in the hospital but the period of "active treatment" ends (e.g., because the 
treatment cannot reasonably be expected to improve the patient's condition, or because 
intensive treatment services are not being furnished), program payment can no longer be 
made even though the patient has not yet exhausted his/her benefits.  Where the period of 
"active treatment" ends, the physician is to indicate the ending date in making his 
recertification.  If "active treatment" thereafter resumes, the physician should indicate, in 
making his recertification, the date on which it resumed. 
 
10.9.1 - Delayed/Lapsed Certification and Recertification 
(Rev 98, Issued: 05-13-16, Effective: 08-15-16, Implementation: 08-15-16) 
 
IPFs are expected to obtain timely certifications and recertifications.  However, delayed 
certifications and recertifications will be honored where, for instance, there have been an 
oversight or lapse, and a legitimate reason for the delay as noted in Pub. 100-01, 20.1.  
Denial of payment for lack of the required certification and recertification is considered a  technical denial, which means a statutory requirement has not been met.  Consequently, if 
an appropriate certification is later produced, the denial shall be overturned.  Reopenings 
of technical denial decisions may be initiated by the contractor or the provider. 
 
In addition to compliance with the appropriate certification and recertification content 
requirements, delayed certification and recertification must include an explanation for the 
delay and any medical or other evidence which the IPF considers relevant for purposes of 
explaining the delay.  The IPF will determine the format of the delayed certifications and 
recertifications, and the method by which they are obtained.  A delayed certification may 
be included with one or more recertifications on a single signed document.  Separate 
signed documents for each delayed certification and recertification are not required as 
they would be if timely certification and recertification had been completed.  For all IPF 
services, a delayed certification may not extend past discharge.  IPF certification or 
recertification documentation may only be signed by a physician. 
 
20 - Certification for Hospital Services Covered by the Supplementary 
Medical Insurance Program 
(Rev. 50; Issued:  12-21-07; Effective:  09-17-07; Implementation:  01-07-08) 
 
A physician must certify that medical and other health services covered by medical 
insurance which were provided by (or under arrangement made by) the hospital were 
medically required. 
 
Physician certification is not required for the following outpatient services furnished on 
or after January 3, 1968: 
 
  Hospital services and supplies incident to physicians' services rendered to 
outpatients; and  
 
  Diagnostic services furnished by a hospital or which the hospital arranges to 
have furnished in other facilities operated by or under the supervision of the 
hospital or its medical staff. 
 
Hospitals must obtain a physician's certification with respect to other services furnished 
to outpatients. 
 
Primarily, this means that a certification statement is needed for diagnostic services 
furnished under arrangements by a facility that is not operated by or under the 
supervision of the hospital or its organized medical staff, e.g., services obtained from an 
independent laboratory. 
 
This certification requires a brief description of the services and the signature of the 
physician.  It needs to be made only once for a course of treatment.  Where services are 
provided on a continuing basis, such as a course of radium treatments, the physician's 
certification may be made at the beginning or end of the course of treatment, or at any 
other time during the period of treatment.   
There is no requirement that the certification be entered on any specific form or handled 
in any specific way, as long as the approach adopted by the hospital permits the A/B 
MAC (A) to determine that the certification requirement is in fact met.  Therefore, the 
certification could be entered or pre-printed on a form the physician already has to sign; 
or a separate certification form could be used. 
 
In addition, physician's certifications are required for the rental and purchase of durable 
medical equipment (see 70), outpatient therapy, i.e., physical therapy, occupational 
therapy and speech-language pathology services (see Pub. 100-02, Chapter 15, 220). 
 
The Physician Certification Statement requirements for all ambulance providers 
(hospital-owned and operated) and suppliers (independently-owned and operated) are 
located at 42 CFR 410.40 (d) (2) and 410.40 (d) (3). 
 
20.1 - Delayed Certifications and Recertifications 
(Rev. 1, 09-11-02) 
 
Hospitals are expected to obtain timely certification and recertification statements. 
However, delayed certifications and recertifications will be honored where, for example, 
there has been an oversight or lapse. 
 
In addition to complying with the appropriate content requirements, delayed certifications 
and recertifications must include an explanation for the delay and any medical or other 
evidence which the hospital considers relevant for purposes of explaining the delay.  The 
hospital will determine the format of delayed certification and recertification statements, 
and the method by which they are obtained.  A delayed certification and recertification 
may appear in one statement; separate signed statements for each certification and 
recertification would not be required as they would if timely certification and 
recertification had been made. 
 
20.2 - Timing for Certification and Recertification for a Beneficiary 
Admitted Before Entitlement 
(Rev. 1, 09-11-02) 
 
If an individual is admitted to a hospital (including a psychiatric hospital) before he/she is 
entitled to hospital insurance benefits (for example, before attainment of age 65), no 
certification is required as of the date of admission or entitlement.  Certifications and 
recertifications are required as of the time they would be required if the patient had been 
admitted to the hospital on the day he/she became entitled.  (The time limits for 
certification and recertification are computed from the date of entitlement instead of the 
date of admission.) 
 
  30 - Certification and Recertification by Physicians and Allowed 
Practitioners for Home Health Services 
(Rev. 10757; Issued: 05-11-21; Effective: 03-01-20; Implementation: 08-11-21) 
 
In addition to the content below, refer to Pub. 100-02, Medicare Benefit Policy Manual, 
chapter 7, section 30.5 for a complete description of the requirements that must be met in 
order to certify and recertify patient eligibility for Medicare home health services. 
 
30.1 - Content of the Physician Certification 
(Rev. 10757; Issued: 05-11-21; Effective: 03-01-20; Implementation: 08-11-21) 
 
Under both the hospital insurance and the supplementary medical insurance programs, no 
payment can be made for covered home health services that a home health agency (HHA) 
provides unless a physician or allowed practitioner certifies that: 
 
  Home health services are needed because the individual is confined to his/her 
home; 
 
  The individual needs intermittent skilled nursing care, physical therapy and/or 
speech-language pathology services.  Where a patients sole skilled service need 
is for skilled oversight of unskilled services, the physician or allowed practitioner 
must include a brief narrative describing the clinical justification of this need as 
part of the certification, or as a signed addendum to the certification; 
 
  A plan for furnishing such services to the individual has been established and is 
periodically reviewed by a physician or allowed practitioner;  
 
  The services are or were furnished while the individual was under the care of a 
physician or allowed practitioner; and 
 
  The individual had a face-to-face encounter with a physician or an allowed non-
physician practitioner no more than 90 days prior to or within 30 days after the 
start of home health care and the encounter was related to the primary reason the 
patient requires home health services in accordance with requirements described 
in Pub. 100-02, Medicare Benefit Policy Manual, chapter 7, section 30.5.1.1.  The 
certifying physician or allowed practitioner must also document the date of the 
encounter. 
 
Certifications must be obtained at the time the plan of care is established or as soon 
thereafter as possible. 
 
The physician or allowed practitioner must sign and date the plan of care (POC) and the 
certification prior to the claim being submitted for payment; rubber signature stamps are 
not acceptable.  The plan of care may be signed by another physician or allowed 
practitioner who is authorized by the certifying physician or certifying allowed 
practitioner who established the plan of care, to care for his/her patients in his/her  absence. The HHA is responsible for ensuring that the physician or allowed non-
physician practitioner who signs the plan of care and recertification statement was 
authorized by the physician or allowed practitioner who established the plan of care and 
completed the certification for his/her patient in his/her absence. While the regulations 
specify that documents must be signed, they do not prohibit the transmission of the POC, 
oral order, or certification via facsimile machine.  The HHA is not required to have the 
original signature on file.  However, the HHA is responsible for obtaining original 
signatures if an issue surfaces that would require verification of an original signature. 
 
Home health agencies that maintain patient records by computer rather than hard copy 
may use electronic signatures.  However, all such entries must be appropriately 
authenticated and dated.  Authentication must include signatures, written initials, or 
computer secure entry by a unique identifier of a primary author who has reviewed and 
approved the entry.  The HHA must have safeguards to prevent unauthorized access to 
the records and a process for reconstruction of the records upon request from the 
Medicare contractor, state surveyor, or other authorized personnel, in the event of a 
system breakdown. 
 
See 10.1 for the effects of failure to certify or recertify. 
 
30.2 - Method and Disposition of Certifications for Home Health 
Services 
(Rev. 92, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15) 
 
There is no requirement that the certification or recertification be entered on any specific 
form or handled in any specific way as long as the Medicare contractor can determine, 
where necessary, that the certification and recertification requirements are met.  The 
certification by the physician must be retained by the HHA. 
 
The following instructions pertain to required documentation of the certification and 
recertification period. 
 
The HHA enters the month, day, year, e.g., MMDDYYYY that identifies the period 
covered by the physician's POC. The "From" date for the initial certification must match 
the start of care (SOC) date.  The "through" date is up to and including the last day of the 
episode which is not the first day of the subsequent episode.  The "through" date can be 
up to, but never exceed a total of 60 days that includes the SOC date plus 59 days. 
 
Example:  Initial certification "From" date 10012000; Initial certification "through" date 
11292000; Re-certification "From" date 11302000; Re-certification "through" date 
01282001. 
 
NOTE:  Services delivered on 11292000 are covered in the initial certification episode. 
 
30.3 - Recertifications for Home Health Services 
(Rev. 92, Issued: 04-22-15, Effective: 01-01-15, Implementation: 05-11-15)   
Under both the hospital insurance and supplementary medical insurance programs, when 
services are continued past an initial 60-day episode of care, the physician must recertify 
at intervals of at least once every 60 days that there is a continuing need for services in 
accordance with requirements described in Pub. 100-02, Medicare Benefit Policy 
Manual, chapter 7, section 30.5.2.  The recertification should be obtained at the time the 
plan of care is reviewed since the same interval (at least once every 60 days) is required 
for the review of the plan. 
 
The physician must include an estimate of how much longer the skilled services will be 
required and must certify that: 
 
1.  The home health services are or were needed because the patient is or was confined to 
the home as defined in Pub. 100-02, Medicare Benefit Policy Manual, chapter 7, section 
30.1; 
 
2.  The patient needs or needed skilled nursing services on an intermittent basis (other 
than solely venipuncture for the purposes of obtaining a blood sample), or physical 
therapy, or speech-language pathology services; or continues to need occupational 
therapy after the need for skilled nursing care, physical therapy, or speech-language 
pathology services ceased.  Where a patients sole skilled service need is for skilled 
oversight of unskilled services (management and evaluation of the care plan as defined in 
Pub. 100-02, Medicare Benefit Policy Manual, chapter 7, section 40.1.2.2), the physician 
must include a brief narrative describing the clinical justification of this need as part of 
the recertification, or as a signed addendum to the recertification; 
 
3.  A plan of care has been established and is periodically reviewed by a physician; and 
 
4.  The services are or were furnished while the patient is or was under the care of a 
physician. 
 
Recertifications must be signed by the physician who reviews the plan of care.  The form 
of the recertification and the manner of obtaining timely recertifications are up to the 
individual agency. 
 
40 - Certification and Recertification by Physicians for Extended Care 
Services 
(Rev. 101, Issued: 09-16-16, Effective: 10-18-16, Implementation: 10-18-16) 
 
Payment for covered posthospital extended care services may be made only if a physician 
(or, as discussed in 40.1 of this chapter, a physician extender) makes the required 
certification and, where services are furnished over a period of time, the required 
recertification regarding the services furnished. 
 
The skilled nursing facility is responsible for obtaining the required certification and 
recertification statements and for retaining them in file for verifications, if needed, by the  A/B MAC (A).  The skilled nursing facility determines the method by which the 
certification and recertification statements are to be obtained.  There is no requirement 
that a specific procedure or specific forms be used, as long as the approach adopted by 
the facility permits a verification to be made that the certification and recertification 
requirements are in fact met.  Certification and recertification statements may be entered 
on or included in forms, NOTEs, or other records that would normally be signed in caring 
for a patient, or a separate form may be used.  Except as otherwise specified, each 
certification and recertification statement is to be separately signed.  See Pub. 100-08, 
Medicare Program Integrity Manual, chapter 6, section 6.3 regarding medical review of 
certification and recertification in SNFs. 
 
If the facility's failure to obtain a certification or recertification is not due to a question as 
to the necessity for the services, but rather to the physician's or physician extenders 
refusal to certify based on other grounds (e.g., an objection in principle to the concept of 
certification and recertification), the facility may not bill the program or the beneficiary 
for covered items or services.  The provider agreement, which the facility files with the 
Secretary, precludes it from charging the patient for covered items and services. 
 
If a physician or physician extender refuses to certify because, in his/her opinion, the 
patient does not, as a practical matter, require daily skilled care for an ongoing condition 
for which he/she was receiving inpatient hospital services (or for a new condition that 
arose while in the SNF for treatment of that ongoing condition), the services are not 
covered and the facility can bill the patient directly.  The reason for the refusal to make 
the certification must be documented in the facility records.  For such documentation to 
be adequate, there must be some statement in the facility's records, signed by a physician 
or a responsible facility official, indicating that the patient's physician or physician 
extender feels that the patient does not, as a practical matter, require daily skilled care for 
an ongoing condition for which he/she was receiving inpatient hospital services (or for a 
new condition that arose while in the SNF for treatment of that ongoing condition). 
 
40.1 - Who May Sign the Certification or Recertification for Extended 
Care Services 
(Rev. 120, Issued: 11-02-18, Effective: 12- 04-18, Implementation: 12- 04-18)  
 
A certification or recertification statement must be signed by the attending physician or a 
physician on the staff of the skilled nursing facility who has knowledge of the case, or by 
a physician extender (that is, a nurse practitioner, a clinical nurse specialist or, effective 
with items and services furnished on or after January 1, 2011, a physician assistant) who 
does not have a direct or indirect employment relationship with the facility, but who is 
working in collaboration with the physician. See Pub. 100-02, Medicare Benefit Policy 
Manual at chapter 8, 40.1, for a discussion of direct and indirect employment 
relationships in this context, and at chapter 15, 190.C (for physician assistants), 200.D 
(for nurse practitioners), and 210.D (for clinical nurse specialists), regarding the 
required collaboration between the physician and the physician extender. 
  Ordinarily, for purposes of certification and recertification, a physician must meet the 
definition contained in Chapter 5, 70 of this manual. 
    40.2 - Certification for Extended Care Services 
(Rev. 126, Issued: 10-04-19, Effective: 11-05-19, Implementation: 11-05-19) 
 
The certification must clearly indicate that posthospital extended care services were 
required to be given on an inpatient basis because of the individual's need for skilled care 
on a daily basis for an ongoing condition for which he/she was receiving inpatient 
hospital services prior to transfer to the SNF (or for a new condition that arose while in 
the SNF for treatment of that ongoing condition).  Alternatively, under the regulations at 
42 CFR 424.20(a)(1)(ii), the initial certification can simply affirm that the individual has 
been correctly assigned one of the case-mix classifiers that CMS designates as 
representing the required SNF level of care, as provided in the regulations at 42 CFR 
409.30 (see Pub. 100-02, Medicare Benefit Policy Manual, chapter 8, 30.1, for a 
discussion of the administrative level of care presumption under the SNF PPS). 
 
Certifications must be obtained at the time of admission, or as soon thereafter as is 
reasonable and practicable (see Pub.100-04, Medicare Claims Processing Manual, 
Chapter 6, 120.2, regarding the circumstances under which a resumption of SNF care 
following a temporary break in SNF coverage would be considered a new admission 
under the SNF PPSs Interrupted Stay policy).  The routine admission procedure 
followed by a physician would not be sufficient certification of the necessity for 
posthospital extended care services for purposes of the program. 
 
If ambulance service is furnished by a skilled nursing facility, an additional certification 
is required.  It may be furnished by any physician who has sufficient knowledge of the 
patient's case, including the physician who requested the ambulance or the physician who 
examined the patient upon his arrival at the facility.  The physician must certify that the 
ambulance service was medically required. 
 
40.3 - Recertifications for Extended Care Services 
(Rev. 1, 09-11-02) 
 
The recertification statement must contain an adequate written record of the reasons for 
the continued need for extended care services, the estimated period of time required for 
the patient to remain in the facility, and any plans, where appropriate, for home care.  The 
recertification statement made by the physician does not have to include this entire 
statement if, for example, all of the required information is in fact included in progress. 
 
NOTE:  In such a case, the physician's statement could indicate that the individual's 
medical record contains the required information and that continued posthospital 
extended care services are medically necessary.  A statement reciting only that continued 
extended care services are medically necessary is not, in and of itself, sufficient. 
 
If the circumstances require it, the first recertification and any subsequent recertifications 
must state that the continued need for extended care services is for a condition requiring 
such services which arose after the transfer from the hospital and while the patient was  still in the facility for treatment of the condition(s) for which he/she had received 
inpatient hospital services. 
 
40.4 - Timing of Recertifications for Extended Care Services 
(Rev. 1, 09-11-02) 
 
The first recertification must be made no later than the l4th day of inpatient extended care 
services.  A skilled nursing facility can, at its option, provide for the first recertification to 
be made earlier, or it can vary the timing of the first recertification within the l4-day 
period by diagnostic or clinical categories. Subsequent recertifications must be made at 
intervals not exceeding 30 days.  Such recertifications may be made at shorter intervals as 
established by the utilization review committee and the skilled nursing facility. 
 
At the option of the skilled nursing facility, review of a stay of extended duration, 
pursuant to the facility's utilization review plan (if a UR review plan is in place), may 
take the place of the second and any subsequent physician recertifications.  The skilled 
nursing facility should have available in its files a written description of the procedure it 
adopts with respect to the timing of recertifications.  The procedure should specify the 
intervals at which recertifications are required, and whether review of long-stay cases by 
the utilization review committee serves as an alternative to recertification by a physician 
in the case of the second or subsequent recertifications. 
 
40.5 - Delayed Certifications and Recertifications for Extended Care 
Services 
(Rev. 1, 09-11-02) 
 
Skilled nursing facilities are expected to obtain timely certification and recertification 
statements.  However, delayed certifications and recertifications will be honored where, 
for example, there has been an isolated oversight or lapse. 
 
In addition to complying with the content requirements, delayed certifications and 
recertifications must include an explanation for the delay and any medical or other 
evidence which the skilled nursing facility considers relevant for purposes of explaining 
the delay.  The facility will determine the format of delayed certification and 
recertification statements, and the method by which they are obtained.  A delayed 
certification and recertification may appear in one statement; separate signed statements 
for each certification and recertification would not be required as they would if timely 
certification and recertification had been made. 
 
40.6 - Disposition of Certification and Recertifications for Extended 
Care Services 
(Rev. 1, 09-11-02) 
 
Skilled nursing facilities do not have to transmit certification and recertification 
statements to the A/B MAC (A); instead, the facility must itself certify, in the admission  and billing form that the required physician certification and recertification statements 
have been obtained and are on file. 
 
50 - Physician's Certification and Recertification for Outpatient 
Physical Therapy Occupational Therapy and Speech-Language 
Pathology 
(Rev. 28; Issued:  08-12-05; Effective/Implementation:  09-12-05) 
 
For certification and recertification of outpatient physical therapy, occupational therapy 
and speech-language pathology services see Pub. 100-02, Chapter 15, 220.1.3. 
 
60 - Certification and Recertification by Physicians for Hospice Care 
(Rev. 68, Issued: 04-22-11, Effective: 01-01-11, Implementation: 05-12-11)) 
 
The hospice must obtain written certification of terminal illness for each period of 
hospice care received by an individual.  For the initial 90-day period, the hospice must 
obtain written certification statements from the medical director of the hospice or the 
physician member of the hospice interdisciplinary group, and the individual's attending 
physician (if the individual has one). The certification must specify that the individual's 
prognosis is for a life expectancy of 6 months or less if the terminal illness runs its 
normal course.  Recertification for subsequent periods only requires the written 
certification by the hospice medical director or the physician member of the hospice 
interdisciplinary group.  Certifications and recertifications must be dated and signed by 
the physician and must include the benefit periods to which they apply.  Certifications 
and recertifications must include a brief narrative explanation of the clinical findings that 
supports a life expectancy of 6 months or less. 
 
If written certification is not obtained within 2 calendar days of the initiation of hospice 
care, a verbal certification must be obtained within the 2 days.  A written certification 
from the medical director of the hospice or the physician member of the interdisciplinary 
group must be on file in the beneficiary's record prior to the submission of a claim to the 
Medicare contractor.  If these requirements are not met, no payment may be made for the 
days prior to certification.  Instead payment will begin with the day certification is 
obtained, i.e., the date verbal certification is obtained. 
 
Certifications and recertifications may be completed up to 15 days before the next benefit 
period begins. 
 
For recertifications on or after January 1, 2011, a hospice physician or hospice nurse 
practitioner must have a face-to-face encounter with each hospice patient prior to the 
beginning of the patients third benefit period, and prior to each subsequent benefit 
period.  Failure to meet the face-to-face encounter requirements results in a failure by the 
hospice to meet the patients recertification of terminal illness eligibility requirement.  
The patient would cease to be eligible for the benefit. See Pub. 100-02, Medicare Benefit 
Policy Manual, Chapter 9, Section 20.1, Timing and Content of Certification. 
  70 - DME Certification 
(Rev. 1, 09-11-02) 
 
The DME supplier must retain a copy of the physician's order for DME in its files; and in 
some cases must furnish a Certificate of Medical Necessity to the DME MAC. 
 
80 - Summary Table for Certifications/Recertifications 
(Rev. 84, Issued: 04-04-14, Effective: 05-05-14, Implementation: 05-05-14) 
 
The following is a table summarizing the certification/recertification signature 
requirements and timeframes for various provider types.  Please review sections above 
for more detailed information on Certifications/Recertifications and their required 
content: 
    Provider  Who Signs Certification  Certification  Recertification 
Type  Timeframe 
Hospital  Attending physician or by  No later than the  Interval between 
Inpatient  another physician with  12th day of  recertifications not to 
knowledge of the case  hospitalization  exceed 30 days 
with authorization from 
attending physician or by 
a member of hospital's 
medical staff with 
knowledge of the case. 
SNF  Attending physician or  Obtain at time of  First recertification no 
physician on staff at SNF  admission or shortly  later than the 14th day 
with knowledge of case,  thereafter  of inpatient extended 
or physician extender  as  care services. 
discussed in 40.1 of this  Subsequent at intervals 
chapter  not exceeding 30 days. 
HHA  Attending physician  Obtain at time POC  Physician must 
is established or  recertify at least once 
shortly thereafter  every 60 days 
Hospice  For initial 90-day period,  If written  Must be obtained for 
must obtain written  certification is not  each period of hospice 
certification statements  obtained within 2  care; written 
from medical director of  calendar days of the  certification by hospice 
hospice or physician  initiation of hospice  medical director or 
member of the hospice  care, a verbal  physician member of 
interdisciplinary group  certification must be  interdisciplinary group. 
and the attending  obtained. 
physician. 
  Transmittals Issued for this Chapter 
 
Rev #  Issue Date Subject  Impl Date  CR# 
R10757GI 05/11/2021 Physician Certification and Recertification of  08/11/2021 12222 
Services Manual Update to Incorporate Allowed 
Practitioners into Home Health Policy 
R126GI  10/04/2019 Manual Updates for CR11152 Implementation  11/05/2019 11454 
of the Skilled Nursing Facility (SNF) Patient 
Driven Payment Model (PDPM) 
R120GI  11/02/2018 Internet Only Manual Updates to Pub. 100-01,  12/04/2018 11004 
100-02 and 100-04 to Correct Errors and 
Omissions (SNF) (2018 Q4) 
R114GI  03/16/2018 Internet Only Manual Updates to Pub. 100-01,  06/19/2018 10512 
100-02 and 100-04 to Correct Errors and 
Omissions (SNF) (2018) 
R101GI  09/16/2016 Internet Only Manual Updates to Pub. 100-01,  10/18/2016 9748 
100-02 and 100-04 to Correct Errors and 
Omissions (SNF) 
R98GI  05/13/2016 Clarification of Inpatient Psychiatric Facilities  08/15/2016 9522 
(IPF) Requirements for Certification, 
Recertification and Delayed/Lapsed 
Certification and Recertification 
R94GI  10/16/2015 Internet Only Manual Updates to Pub. 100-01,  11/16/2015 9336 
100-02 and 100-04 to Correct Errors and 
Omissions (2015) 
R92GI  04/22/2015 Manual Updates to Clarify Requirements for  05/11/2015 9119 
Physician Certification and Recertification of 
Patient Eligibility for Home Health Services 
R91GI  04/10/2015 Manual Updates to Clarify Requirements for  05/11/2015 9119 
Physician Certification and Recertification of 
Patient Eligibility for Home Health Services  
Rescinded and replaced by Transmittal 92 
R84GI  04/04/2014 Internet Only Manual Updates to Pub. 100-01,  05/05/2014 8669 
100-02 and 100-04 to Correct Errors and 
Omissions 
R76GI  01/13/2012 Allowing Physician Assistants to Perform  02/13/2012 7701 
Skilled Nursing Facility (SNF) Level of Care 
Certifications and Recertifications 
R68GI  04/22/2011 Physician Certification and Recertification of  05/12/2011 7377 
Services Manual Changes 
R50GI  12/21/2007 Revision to Certification for Hospital Services  01/07/2008 5833 
Covered by the Supplementary Hospital  Insurance Program as it Pertains to Ambulance 
Services 
R47GI  08/17/2007 Revision to Certification for Hospital Services  09/17/2007 5684 
Covered by the Supplementary Medical 
Insurance Program as it Pertains to Ambulance 
Services 
R39GI  06/09/2006 Update-Inpatient Psychiatric Facilities  07/03/2006 5129 
Prospective Payment System (IPF PPS) Rate 
Year 2007 
R28GI  08/12/2005 Conforming Changes for Change Request 3648  09/12/2005 3912 
to Pub. 100-01 
R01MGI  09/11/2002 Initial Publication of Manual  NA  NA 
 
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