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Know the rules when it comes to Medicare patient recertification

Rehab Regs, May 12, 2003

Know the rules when it comes to Medicare patient recertification

It's one of the basic requirements for outpatient rehab practices-physician recertifications that attest to the need for patients to continue therapy regimens. But the issue of obtaining and tracking physician recertifications for therapy services provided to Medicare patients can cause confusion and occasionally wreak havoc in outpatient rehab provider practices.

The checklist that outpatient rehab providers need to adhere to in order to ensure that they receive recertifications within a timely manner can be daunting. Complicating the issue, CMS regulations for obtaining recertifications vary according to the setting in which therapists practice. And some CMS instructions related to the recertification process remain open to interpretation, industry experts note.

What's at stake? Industry experts say outpatient rehab providers face the risk of compliance trouble and falling off their billing cycle if they don't receive recertifications and carefully document patient follow-up visits to physicians on a timely basis.
When it comes to the issue of recertification, industry experts recommend that you consider the following five tips carefully:

Understand the process. Consider the example of Sally Jones, a Medicare beneficiary who receives a prescription for therapy from her physician and shortly thereafter shows up at the Parkview Rehab Clinic, a hospital-based outpatient rehab provider.

When therapists at Parkview first see Sally, as with all Medicare patients, they will perform an evaluation, establish goals and a plan of care (POC), which they then send to Rick Gawenda, PT, director of rehab services for Detroit Receiving Hospital in Detroit for his signature.

Under the timetable adhered to by outpatient rehab facilities, therapists at Parkview must obtain a recertification from the physician 30 calendar days after the initial visit in order to continue to provide therapy to Sally.

In order to do so, therapists have the option of completing the CMS 701 form, which is entitled the Updated Plan of Progress for Outpatient Rehabilitation. As this form is not required, outpatient rehab facilities may develop their own equivalent, Gawenda says. This form-which contains the elements found on the 701 form and is based upon progress notes-would state how the patient is progressing, his or her current functional status, and outline new goals and reasons for continuing therapy.

Once complete, this process would then continue on the 30-calendar day cycle.

Remember that FI interpretations vary. While regulations mandate recertification needs to occur every 30 days in outpatient rehab settings, CMS further stipulates that patients must fall under the care of a physician, and patients must visit the physician every 30 days. However, there are gray areas when it comes to interpreting this requirement.

"CMS did not clarify whether the physician visit needs to occur every 30 days from [the date] on which the patient started therapy, or when he or she first saw the physician," Gawenda says.

"The physician may have seen the patient on March 1 and the patient started PT on March 15. The question is, when is the patient supposed to see the physician? Is it by March 31 [30 days after the initial physician visit] or April 13 [30 days after the patient first began PT]?"

Fiscal intermediaries [FIs] and carriers vary when it comes to interpreting the regulations, Gawenda notes. Some prohibit therapists from treating patients until they receive a signed recertification, while others may put in place a two-week window.

Outpatient rehab providers should pose the question to their FIs or carriers and receive a written response, which they should keep on file, with regard to the specific interpretation policy, Gawenda says.

Carefully document patient visits to physicians. From a compliance standpoint, providers should take care to document within the record the details of the patient's visit to the physician, Gawenda says. Oftentimes, providers-who may receive the recertification form later via fax from the physician-must take the word of the patient that the visit occurred.

Outpatient rehab providers should note that the industry organizations-including the American Physical Therapy Association and the American Occupational Therapy Association-are in the midst of a lobbying effort to overturn the physician visit requirement. Many within the industry question the judgment behind the requirement.

"Since the physician's signing the recertification, it means he or she is in agreement with the plan of care and the need for continued therapy," Gawenda says. "Why do the patients then have to be sent to the physician's office? It's an inconvenience to the patient, and it's an inconvenience to the physician."

Develop a tracking system. If your practice treats large numbers of Medicare patients, the prospect of tracking recertifications can seem overwhelming. There are a number of strategies providers can take to obtain recertifications within a scheduled timetable.

For example, one employee at the Wuesthoff Health System is responsible for tracking insurance information-including recertifications-at all six of the system's outpatient rehab clinics, says Karen Holifield, director of rehabilitation services. With more than 70% of its patient mix Medicare beneficiaries, the employee visits the outpatient sites once a week, Holifield says.

"She goes through all of the files and checks to see that we have both the recertification and the signed plan of care," Holifield says.

Prior to the establishment of this staff position, therapists were responsible for tracking by making notations on a tracking sheet attached to the patient chart of when the recertification and plan of care was due.

Keep patients informed of the process. Occasionally, outpatient rehab providers can find themselves waiting for physicians-whether it be for a signed plan of care or a recertification. A breakdown in the scheduling at the physician's office or just plain business may be to blame. No matter the cause, however, the wait-and the effect it can have on the treatment of the patient-can be frustrating.

Holifield recommends that you pay attention to the stipulations set by your FI or carrier and be up front with the patient about the issue.

For example, Holifield's FI allows three patient visits to occur without a signed plan of care.

"If we haven't had the plan of care back from the physician's office within that window, we will explain to the patient why the therapy can't continue past the date," Holifield says. "Oftentimes, the patient calls the physician's office directly . . . and we soon receive a signed plan of care."



Determine your recertification timetable

Freestanding and hospital-based outpatient rehab facilities, skilled nursing facilities (SNFs), home health, and comprehensive outpatient rehabilitation facilities (CORFs), are all required to obtain recertifications under different timetables. The following timetables are outlined in the Code of Federal Regulations (CFR):

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