Medicare Plan of Care Certification for Therapy
Every Medicare Part B therapy claim rests on a plan of care that a physician or nonphysician practitioner (NPP) has certified, and the timing rules around that certification are stricter than most practices treat them. Initial certification is due within 30 days of the first treatment. Recertification is due at least every 90 days, and that clock does not move for anyone, not even under the newest exception. A late certification is forgivable up to 30 days past due; beyond that, the practice has to document why.
Since January 1, 2025, there’s also a genuine shortcut: when a written referral is already in the chart and a therapist establishes the plan, the referral itself can satisfy initial certification, and the physician’s silence can stand in for a signature. That exception does not touch recertification, and it does not apply to direct access patients who walked in without a referral at all.
This post works from the certification regulation at 42 CFR 424.24, the Medicare Benefit Policy Manual (Pub. 100-02, Ch. 15, §220), and the CY 2025 Physician Fee Schedule final rule (89 Fed. Reg. 97710, 97912-97918). Current as of August 2026.
The rules break into two questions that get answered separately but are frequently blurred in practice: who is allowed to sign, and how many days do they have to do it. Getting the first question wrong means the wrong signature is on the chart. Getting the second wrong means a technically valid signature arrives too late to cover the services already billed.
What a plan of care must contain
At minimum, a Medicare-compliant plan of care must state the diagnoses, the long-term treatment goals, and the type, amount, duration, and frequency of therapy services (42 CFR 424.24; Pub. 100-02 Ch. 15 §220). Those elements are what the certifying provider is attesting to when they sign, not the day’s treatment note, but the plan governing the episode. A plan of care missing any of the four is incomplete regardless of whether a physician or NPP later signs it, since the signature certifies a plan that meets the content standard in the first place.
Who can establish a plan and who can certify it
Medicare separates two roles that practices sometimes collapse into one. A plan of care can be established by a physician, an NP, a PA, a clinical nurse specialist (CNS), or by the treating PT, OT, or SLP. It can only be certified by a physician, NP, PA, or CNS who has knowledge of the case (42 CFR 424.24(c); Pub. 100-02 Ch. 15 §220).
| Role | Can establish the plan | Can certify the plan |
|---|---|---|
| Physician | Yes | Yes |
| NP, PA, or CNS | Yes | Yes |
| PT, OT, or SLP | Yes | No |
| Chiropractor or dentist | No | No |
What that means in practice: if the physician or NPP is the one who establishes the plan, they’re certifying their own work and simply sign it. If the therapist establishes the plan, someone else has to certify it, which is where the 30-day and 2025-exception rules come in below. Two providers are excluded from this pathway entirely: chiropractors and dentists may not refer patients for therapy and may not certify therapy plans of care (42 CFR 424.24(c); Pub. 100-02 Ch. 15 §220).
Initial certification: the 30-day rule
Initial certification must be obtained “as soon as possible after the plan is established,” and no later than 30 calendar days after the first therapy treatment under that plan (42 CFR 424.24(c); Pub. 100-02 Ch. 15 §220). The clock starts at the initial treatment date, not the evaluation date and not the date the plan was written, and it runs regardless of how many visits happen inside that window. A practice that sees a patient twice a week can easily be eight or nine visits into an episode before day 30 arrives, all of them resting on a certification that hasn’t been obtained yet.
Until 2025, that 30-day window meant the same thing for every patient: someone had to get an actual signature from a physician or NPP within it. The exception below changes that for one specific, common scenario.
The 2025 exception: when silence counts as certification
Effective January 1, 2025, CMS built a narrower path for the most common scenario in outpatient therapy: a physician or NPP refers a patient, and the treating therapist establishes the plan of care from that referral. Under the exception, if a signed and dated order or referral from the physician/NPP is already in the record, that document itself can satisfy the initial certification requirement, and the therapist does not need to chase down a separate signature on the plan of care (42 CFR 424.24(c); CY 2025 PFS final rule, 89 Fed. Reg. 97912-97918).
The exception has a sequence, and each step has to happen for it to hold:
- A signed and dated order or referral from the physician/NPP exists in the patient’s record.
- The therapist establishes the plan of care from that referral.
- The therapist documents evidence that the plan of care was transmitted to the referring physician/NPP, within 30 days of the initial evaluation.
- The referring provider has the opportunity to review it and either return a signature or flag a change.
- If nothing comes back, silence serves as consent, and the original order or referral stands in for the certification signature.
CMS framed the change as one that “lessens the administrative burden for therapists and physician/NPPs while maintaining appropriate oversight” (89 Fed. Reg. 97912-97918). Note what the exception does and doesn’t remove: the therapist still has to prove the plan was sent, just not that it came back signed.
The exception has real edges. It does not apply to:
- Direct access patients, because there’s no referral in the record for the exception to lean on
- Recertification, at any point in the episode
- Home health therapy, which follows its own certification framework
Recertification: the 90-day clock
Recertification is due at least every 90 days from the date of initial certification, or sooner if the patient has a significant change in status, whichever comes first (42 CFR 424.24; Pub. 100-02 Ch. 15 §220). Each certified period can run no longer than 90 calendar days, so a plan can’t coast on its initial certification indefinitely.
A significant change resets the clock immediately. It doesn’t wait for the next scheduled 90-day deadline; the recertification is due as soon as the change occurs.
The 2025 silence-as-consent exception explicitly does not extend to recertification. CMS was direct about why: to “ensure that a patient does not receive unlimited therapy services without a treatment plan signed and dated by the patient’s physician/NPP.” Recertification still requires an actual, dated signature from the physician or NPP, and the plan has to indicate a continuing need for therapy before that signature is given (42 CFR 424.24; Pub. 100-02 Ch. 15 §220; CMS IOM).
| Requirement | Initial certification | Recertification |
|---|---|---|
| Deadline | Within 30 days of first treatment | Every 90 days from initial certification, or sooner on significant change |
| 2025 exception applies | Yes (with a referral on file) | No |
| Signature required | Physician/NPP, or referral document under the exception | Physician/NPP signature and date, always |
| Maximum period covered | N/A | 90 calendar days per certification |
Recertification is not the same thing as re-evaluation
These two get conflated because they tend to happen around the same point in an episode, but they’re procedurally and financially distinct. Recertification is an administrative act: the physician/NPP signs off that the plan of care remains appropriate, and it isn’t separately billable. Re-evaluation is a clinical service, performed by the therapist, that carries its own CPT code and is separately payable. Completing one does not satisfy the other, and a chart that has a re-evaluation note but no recertification signature is still missing the certification requirement (42 CFR 424.24; Pub. 100-02 Ch. 15 §220; CMS IOM).
Delayed certification: how much slack exists
Certifications that come in late aren’t automatically fatal to the claim. Medicare accepts a delayed certification without justification if it arrives within 30 days after the due date, whether that due date is the 30-day initial deadline or a 90-day recertification deadline (Pub. 100-02 Ch. 15 §220.1.3).
Past that 30-day grace period, the standard changes. The provider must document justification for the delay along with evidence of reasonable efforts to obtain the certification, commonly understood as multiple documented contact attempts (at least three is the benchmark most MACs apply) with the certifying physician or NPP (Pub. 100-02 Ch. 15 §220.1.3). Without that documentation, a late certification found in an audit has nothing behind it.
| How late | What’s required |
|---|---|
| 0 to 30 days past due | Nothing beyond the certification itself; no justification needed |
| More than 30 days past due | Documented justification for the delay, plus evidence of reasonable efforts (at least 3 contact attempts with the certifying physician/NPP) |
The 30-day grace period is a cushion, not a second deadline to plan around. A practice that routinely relies on it is one contact attempt short of falling into the second row of that table.
Verbal orders and signature rules
A verbal certification or recertification is acceptable, but the physician or NPP has to sign and date it within 14 calendar days (Pub. 100-02 Ch. 15 §220). Left unsigned past that window, a verbal order doesn’t satisfy the certification requirement, and a verbal order that’s never followed up on is functionally no certification at all.
On signatures generally: real (wet) signatures and electronic signatures both count. Stamped signatures do not (42 CFR 424.24; Pub. 100-02 Ch. 15 §220). If a formal certification document is missing from the chart, a physician’s progress note that indicates agreement with the plan of care can serve as certification instead, so the requirement isn’t strictly tied to a single document type; what matters is that the physician’s or NPP’s agreement with the plan is dated and in the record somewhere. And on the claim itself, the certifying provider’s name and NPI need to appear in the ordering/referring physician field, connecting the billed service back to the person who certified it (42 CFR 424.24; Pub. 100-02 Ch. 15 §220). A claim where that field doesn’t match the certifying signature in the chart is a mismatch an auditor will notice before they read a single progress note.
Direct access patients still need a certified plan
Medicare does not require a physician order or referral to start outpatient therapy. Patients can come in through direct access. But that pathway doesn’t remove the certification requirement: the patient still has to be “under the care of” a physician or NPP, and the plan of care still has to be certified under the standard 30-day and 90-day rules (42 CFR 424.24).
What direct access patients don’t get is the 2025 exception. Since there’s no physician order or referral sitting in the record, there’s nothing for the exception to substitute for certification, so these patients need an actual certification obtained the traditional way.
For more on how direct access interacts with billing and documentation more broadly, see the documentation requirements post.
What happens when certification is missing
The exposure here isn’t hypothetical paperwork risk. Services furnished after a certification period has expired, and before a valid recertification is obtained, can be denied as noncovered by Medicare (CMS audit guidance; MAC policies). If an auditor pulls a chart and finds no certification at all, the services can be deemed not medically necessary. When that happens, Medicare can demand the return of payments, plus interest and penalties (CMS audit guidance; MAC policies). See the claim denials post for how these findings typically surface during review.
A missed 90-day recertification deadline is a frequent finding in therapy claim reviews precisely because it’s a date, not a clinical judgment call, and dates are what auditors check first. Unlike a documentation gap that requires interpretation, a missing or late signature is binary: either the date on the certification falls inside the required window or it doesn’t, which is exactly why certification tracking rewards a system rather than a person’s memory of who was supposed to sign what.
Certification deadlines don’t announce themselves; they arrive on day 27 of an initial window or day 88 of a recertification period whether or not anyone noticed. PrismEHR tracks each certification period against the patient’s initial certification date and alerts before the 90-day recertification deadline, and under the 2025 exception, it documents the evidence that a plan of care was transmitted to the referring provider, so the record supports the certification instead of leaving it to memory. Paired with the modifier and threshold rules covered in the CQ/CO modifier and KX threshold posts, it’s one more compliance date that shouldn’t depend on someone’s calendar reminder. See how it fits physical therapy practices.