Hang onto your hats with this 2025 Medicare Physician Fee Schedule proposed rule and therapy plan certification

Get ready for a shake-up! The 2025 Medicare Physician Fee Schedule (MPFS) proposed rule has dropped, bringing with it crucial changes that every therapist needs to know. From payment rates to telehealth and therapy plan certifications, I discuss here what’s new and what it means for you.

On July 10, 2024, the Centers for Medicare & Medicaid Services released the CY2025 Payment Policies under the Physician Fee Schedule proposed rule. Key highlights included standard updates to payment rates and conversion factors, telehealth, supervision rules, and upcoming MIPS changes. 

Additional, and perhaps unexpected, proposals were also included regarding certification of therapy plans of care with a physician or NPP order.

For all the regulatory gurus, nerds and Medicare Benefit Policy Manual Chapter 15 enthusiasts out there, this is good stuff and should not be overshadowed by other elements in the rule.

The proposal also seems to reflect a continued focus from CMS on the reduction of administrative burden with a move towards more of a patient-centered culture and meeting individual needs in a timely manner. 

We, as therapists, have all experienced or witnessed the push-pull that comes with meeting technical requirements around certification while also meeting the immediate needs of those we serve daily.

So what is the proposal, you ask?

We begin with what we know to be true today about the need for certification.

Regulation requires that an individual outpatient is under the care of a physician and for whom a plan for the physical therapy, occupational therapy or speech-language pathology services that are to be furnished has been established by a physician or by a qualified PT, OT or SLP and is periodically reviewed by a physician. 

Sections 1835(a)(2)(C) and 1835(a)(2)(D) of the Act require that payment for Medicare therapy services may be made for outpatient physical therapy, occupational therapy and speech-language pathology services only if a physician certifies (and recertifies, where such services are furnished over a period of time) that: 

(a) The services are or were required because the patient needs or needed therapy services; 

(b) A plan for furnishing such services was established by a physician or qualified therapist providing such services, and is periodically reviewed by the physician; and 

(c) The services are or were furnished while the individual was under the care of a physician. 

Next, we are reminded of what is true regarding time frames for certification.

In Pub. 100-02, chapter 15, section 220.1.3 for Certification and Recertification of Need for Treatment and Therapy Plans of Care, we specify that the physician or nonphysician practitioner (NPP) must sign the initial plan of care (POC) with a dated signature or verbal order within 30 days from the first day of treatment, including evaluation (or 14 days if a verbal order), in order for the PT, OT, or SLP to be paid for the services. 

What happens if we don’t meet the 30 days? 

The manual allows for a delayed certification when the physician or NPP completes certification and includes a reason for the delay, and delayed certifications are accepted without justification up to 30 days after the due date. 

What about certification limits? 

The regulations at § 424.24(c)(4) require recertification at least every 90 days, and the plan or other documentation in the patient’s medical record must indicate the continuing need for physical therapy, occupational therapy, or speech-language pathology services. 

The physician, nurse practitioner, clinical nurse specialist or physician assistant who reviews the plan must recertify the plan by signing the medical record. 

So why are changes stated to be considered in the proposal?

Over the past two years, representatives of several therapy-related organizations have requested that CMS reduce the administrative burden involved with attempting to obtain signed plans of treatment from the physician/NPP. 

They expressed concern that therapists are held accountable for the action or inaction of physicians/NPPs who may be overwhelmed with paperwork. These interested parties report that therapists make exhaustive efforts to obtain the physician/NPP’s signature – some reporting that they contact physician offices (via phone, email, fax, etc.) more than 30 times.

Without the required signature, the therapist will not meet the conditions to be paid for the services they deliver. These interested parties recommend that payment for therapy services should be determined by the medical necessity of the service and whether the therapist has met their statutory and regulatory requirements.

Accordingly, such interested parties have said that care is delayed while awaiting a physician’s signature, which could place the beneficiary’s health at risk due to the delay in obtaining outpatient therapy services. 

What is the CMS response?

They state, “While we do not require an order or referral for a Medicare patient to see a PT, OT, or SLP, we have explained that the presence of a signed order from the treating physician satisfies statutory requirements that therapy is/was medically necessary and the patient is/was under the care of a physician” (Pub. 100-02, chapter 15, section 220.1.1). 

Furthermore, they state after reviewing current regulatory requirements and considering the suggestions of interested parties, they believe it would be appropriate to propose to amend the regulation at § 424.24(c) for those cases when a patient has a signed and dated order/referral from a physician/NPP for outpatient therapy services. 

Since the policy has been to accept the physician or NPP’s signature on the plan of treatment to be their certification of the treatment plan’s conditions in the content requirements of § 424.24(c)(1) ─ that the patient needs or needed physical therapy, occupational therapy or speech-language pathology services, the services were furnished while the individual was under the care of a physician, NP, PA, or CNS, and the services were furnished under a plan of treatment that meets the requirements of § 410.61.

What does the current proposal state?

They propose that a signed and dated order/referral from a physician/NPP, combined with documentation of such order/referral in the patient’s medical record and further evidence in the medical record that the therapy plan of treatment was transmitted/submitted to the ordering/referring physician or NPP, is sufficient to demonstrate the physician or NPP’s certification of these required conditions.

They believe this would be reflective of the intent of the ordering/referring physician/NPP when that order/referral is on file in the patient’s medical record. 

Furthermore, it is stated that this would still be consistent with the initial certification required under section 1835(a) of the Act for providers of therapy services and our current policy for therapy in the private practice setting. 

When the ordering/referring physician writes the referral for the type of therapy services, they determine their patient needs or needed, they also review the treatment plan the therapist established at the time it is forwarded to them, and they verify that the services are or were furnished while the patient is or was under their care.

 As such, we propose to carve out an exception to the physician signature requirement at § 424.24(c) by adding a new paragraph (c)(5). 

The proposed policy would be an exception to the physician signature requirement for purposes of an initial certification in cases where a signed and dated order/referral from a physician, NP, PA, or CNS is on file and the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation. 

What about recertification, you ask?

Currently, they are not proposing and do not intend to establish an exception to the signature requirement for purposes of recertification of the therapy plan of treatment. 

CMS believes that physicians and NPPs should still be required to sign a patient’s medical record to recertify their therapy treatment plans, in accordance with § 424.24(c)(4), to ensure that a patient does not receive unlimited therapy services without a treatment plan signed and dated by the patient’s physician/NPP. 

So, what are the next steps in providing comments to CMS?

To be assured consideration, comments must be received no later than 5 p.m. on September 9, 2024.

It is crucial for therapists to review the proposed changes, understand their potential impact, and actively participate in the public comment process to ensure that their voices are heard and that the final rule supports both clinical practice and patient care.

Renee Kinder, MS, CCC-SLP, RAC-CT, serves as the Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she contributes her expertise as a member of the American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, the University of Kentucky College of Medicine community faculty, and an advisor to the American Medical Association’s (AMA) Current Procedural Terminology CPT® Editorial Panel, and a member of the AMA Digital Medicine Payment Advisory Group. For further inquiries, she can be contacted here.

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