(Medicare Benefit Policy Manual)

D.  Delayed Certification   References:  1835(a)  of the Act  42CFR424.11(d)(3)   Certifications are required for each interval of treatment based on the patients needs, not to exceed 90 calendar days from the initial therapy treatment.  Certifications are timely when the initial certification (or certification of a significantly modif ied plan of care) is dated within 30 calendar days of the initial treatment under that plan.  Recertification is timely when dated during the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whicheve r is less.  Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay.  Certifications are acceptable without justification for 30 days after they are due.  Delayed certification should include one or more certifications or recertifications on a single signed and dated document.  Delayed certifications should include any evidence the provider or supplier considers necessary to justify the delay.  For example, a certification may be delayed because the physician did not sign it, or the original was lost.  In the case of a long delayed 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 patients care, or treatment did not meet the patients 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, re quests for certification, certifications for intervals before or after the service in question, or physician/NPP services during which the medical record or the patients history would, in good practice, be reviewed and would indicate therapy trea tment 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 episode i s delayed.  If a certified plan of care ends March 30th and a new plan of care for continued treatment after March 30th is developed or signed by a therapist on April 15th and that plan is subsequently certified, that certification may be considered delaye d and acceptable effective from the first treatment date after March 30th 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).   For example, if a patient is treated and the provider/supplier cannot produce (on contractor request) a plan of care (timely or delayed) for the billed treatment dates certified by a physician/NPP, then that service might be denied for lack of the required certification.  If an appropriate certification is later produced, the denial shall be overturned.   In the case of a service furnished under a provider agreement as described in 42CFR489.21, the provider is precluded from charging the beneficiary for services denied as a result of missing certification.   However, if the service is provided by a supplier (in the office of the physician/NPP, or therapist) a technical denial due to absence of a certification results in beneficiary liability.  For that reason, it is recommended that the patient be made aware o f the need for certification and the consequences of its absence.   A technical denial decision may be reopened by the contractor or reversed on appeal as appropriate, if delayed certification is later produced.  220.1.4 - Requirement That Services Be Furnished on an Outpatient Basis  (Rev. 179, Issued: 01- 14-14, Effective: 01 -07-14, Implementation: 01- 07-14)  Reference:  42CFR410.60  Therapy services are payable under the Physician Fee Schedule when furnished by 1.) a provider to its outpatients in the patients home; 2.) a provider to patients who come to the facilitys outpatient department;  3.) a provider to inpatients of other ins titutions, or 4.) a supplier to patients in the office or in the patients home.  (CORF rules differ on providing therapy at home.)   Coverage includes therapy services furnished by participating hospitals and SNFs to their inpatients who have exhausted Part A inpatient benefits or who are otherwise not eligible for Part A benefits.  Providers of therapy services that have inpatient faci lities, other than participating hospitals and SNFs, may not furnish covered therapy services to their own inpatients.  However, since the inpatients of one institution may be considered the outpatients of another institution, all providers of therapy services may furnish such services to inpatients of another health facility.   A certified distinct part of an institution is considered to be a separate institution from a nonparticipating part of the institution.  Consequently, the certified distinct part may render covered therapy services to the inpatients of the noncertified par t of the institution or to outpatients.  The certified part must bill the A/B MAC (A) under Part B.  Therapy services are payable when furnished in the home at the same physician fee schedule payment rates as in other outpatient settings.  Additional expenses incurred by providers of outpatient therapy due to travel to the beneficiary are not covered.  Under the Medicare law, there is no authority to require a provider to furnish a type of service.  Therefore, a hospital or SNF may furnish therapy to its inpatients without having to set up facilities and procedures for furnishing those services to its outpatients.  However, if the provider chooses to furnish a particular service, it may not charge any individual or other person for items or services for which the individual is entitled to have payment made under the program because it is bound by its agreement with Medicare.  Thus, whenever a hospital or SNF furnishes outpatient therapy to a Medicare beneficiary (either directly or under arrangements with others) it must bill the program under Part B and may charge the patient only for the applicable deductible and coinsurance.  220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy Services  (Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)    References:  Pub. 100-08, chapter 13, 13.5.1, 42CFR410.59 , 42CFR410.60   A.  General   To be covered, services must be skilled therapy services as described in this chapter and be rendered under the conditions specified.  Services provided by professionals or personnel who do not meet the qualification standards, and services by qualified people that are not appropriate to the setting or conditions are unskilled services.  A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist.  If a service can be self -administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service.  Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service whe n a therapist furnishes the service.   Skilled therapy services may be necessary to improve a patients current condition, to maintain the patients current condition, or to prevent or slow further deterioration of the patients condition.  For further information see 220.2, subsections C (Reha bilitative Services) and subsection D (Maintenance Programs).   Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services.  For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes.  Also, services not provided under a therapy plan of care, or provided by staff who are not qualified or appropriately supervised, are not payable therapy services.  Examples of coverage policies that apply to all outpatient therapy claims are in this chapter, in Pub. 100-04, chapter 5, and Pub. 100-08, chapter 13 .  Some policies in other manuals are repeated here for emphasis and clarification.  Further details on documenting reasonable and necessary services are found in section 220.3 of this chapter.  B.  Reasonable and Necessary   To be considered reasonable and necessary, each of the following conditions must be met. (This is a representative list of required conditions and does not fully describe reasonable and necessary services.  See the remainder of this section and associated information in section 230.)   The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patients condition.  Acceptable practices for therapy services are found in:   o Medicare manuals (such as this manual and Publications 100-03 and 100- 04),  o Contractors Local Coverage Determinations (LCDs and NCDs are available on the Medicare Coverage Database:  http://www.cms.hhs.gov/mcd , and  o Guidelines and literature of the professions of physical therapy, occupational therapy and speech -language pathology.   The services shall be of such 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.  Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.  Medicare coverage does not turn on the presence or absence of a beneficiarys potential for improvement from the therapy, but rather on the beneficiarys need for skilled care.  (For additional guidance, see subsection D below related to Maintenance Programs.)    If the contractor determines the services furnished were of a type that could have been safely and effectively performed only by or under the supervision of such a qualified professional, the contractor shall presume that such services were properly superv ised when required.  However, this presumption is rebuttable and, if in the course of processing a claim, the contractor finds that services were not furnished under proper supervision, it shall deny the claim and bring this matter to the attention of the Division of Survey and Certification of the Regional Office.    While a beneficiarys particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiarys diagnosis or prognosis cannot be the sole factor in deciding that a service is or is not skilled.  The key issue is whe ther the skills of a therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel. See items C and D for descriptions of covered skilled services; and   The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.  The contractor shall consult local professionals or the state or national therapy associations in the development of any utilization guidelines.