Medicare and Out of State Referrals
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12/10/2015 at 5:10:36 PM GMT
Posts: 23
Medicare and Out of State Referrals

There have been lots of questions lately regarding Medicare and out of state scripts, etc.  FPTA received the following information from APTA in hope of clearing this up: 

"I spoke with our federal regulatory attorneys and confirmed that Medicare policy would allow for a Florida PT to submit a plan of care to be certified to the patient’s out-of-state physician, provided this was done within the 21 day direct access window.  For any treatment after 21 days would require the plan of care to be certified by a physician licensed in the state of FL (to meet the requirements of the FL PT law) and the patient’s physician (to meet Medicare payment policy).

There is nothing explicit in the Medicare Policy Manual that specifically says “a PT can have a plan of care certified by an out-of-state physician.” Medicare does state that practitioners must first meet the requirements of their state licensure law, and defers to state law for any restrictions. If a state licensure law is more restrictive than Medicare, then the practitioner needs to follow that first.

The only thing we can point members to in writing is the Medicare Policy Manual which outlines what folks need to follow if they want to get paid by Medicare.  The policy manual can be found online at:

Of interest is Section 220.1.1-3, which outline payment for outpatient PT/OT/Speech, which is found on pages 159-166.  I have cut and pasted some relevant text from this section of this policy manual below.

Outpatient therapy services furnished to a beneficiary by a provider or supplier are payable only when furnished in accordance with certain conditions. The following conditions apply.

• Services are or were required because the individual needed therapy services (see 42CFR424.24(c), §220.1.3);

• A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP (see 42CFR424.24(c), §220.1.2);

• Services are or were furnished while the individual is or was under the care of a physician (see 42CFR424.24(c), §220.1.1);

In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above three conditions are met (42 CFR 424.24(c)). Certification is required for coverage and payment of a therapy claim.

• Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care. This requirement is effective for claims with dates of service on or after October 1, 2012. (See Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.3.)

• Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the required functional reporting. (See 42CFR410.59, 60, and 62), Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6.)

• The patient functional limitations(s) reported on claims, as part of the functional reporting, must be consistent with the functional limitations identified as part of the therapy plan of care and expressed as part of the patient’s long term goals* (see 42CFR410.61, 42CFR410.105, Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6.)

220.1.1-Care of a Physician/Nonphysician Practitioner (NPP)

Although there is no Medicare requirement for an order, when documented in the medical record, an order provides evidence that the patient both needs therapy services and is under the care of a physician. The certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care (see essential requirements of plan in §220.1.2), no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan

220.1.3-Certification and Recertification of Need for Treatment and Therapy Plans of Care

Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. It is not appropriate for a physician/NPP to certify a plan of care if the patient was not under the care of some physician/NPP at the time of the treatment or if the patient did not need the treatment. Since delayed certification is allowed, the date the certification is signed is important only to determine if it is timely or delayed. The certification must relate to treatment during the interval on the claim. Unless there is reason to believe the plan was not signed appropriately, or it is not timely, no further evidence that the patient was under the care of a physician/NPP and that the patient needed the care is required.

Initial Certification of Plan

The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of the certification requirements noted above in §220.1 for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less. The initial treatment includes the evaluation that resulted in the plan. 


Justin Elliott

Vice President, Government Affairs

American Physical Therapy Association


Liz Aperauch, FPTA
Director, Membership and Social Media

Last edited Thursday, December 10, 2015
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