Corporate Compliance

Ongoing therapy

Compliance Monitor, March 4, 2005

Q: CMS regulations require patients who are receiving physical therapy to be seen by their physicians every 30 days to validate the need for ongoing therapy. If the requirement is not met, the services are considered not covered. Is the hospital outpatient therapy department responsible for verifying that the patient is seen every 30 days? If yes, how do outpatient departments manage to monitor this requirement? Would it be appropriate to obtain an ABN in these situations?

A: It is the responsibility of the provider (e.g., hospital or outpatient clinic) to ensure that a physician or nonphysician provider has certified an initial plan of care and recertified the continued medical necessity for therapy services provided to a Medicare beneficiary every 30 days, as necessary.

One way to track the certification/recertification process is for the therapy provider to establish a log of when the request for cert/recert is sent to the physician's office. Assign a staff person who can ensure that the signed cert/recert has been returned by the physician in a reasonable time frame (two weeks is usually viewed as reasonable by the fiscal intermediary). The staff person would also be responsible for following up with the physician's office, as necessary, to ensure that the signed form is received.

In situations where you do not expect Medicare to deny payment for a service, an advanced beneficiary notice (ABN) should not be given to the patient. For further guidelines on the use of the ABN, visit CMS on the Web.

This question was answered by Mike Megill, Director, ZA Consulting, Jenkintown, PA.

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