42 CFR 424.24 - Requirements for medical and other health services furnished by providers under Medicare Part B.
(a)Exempted services. Certification is not required for the following:
(1) Hospital services and supplies incident to physicians' services furnished to outpatients. The exemption applies to drugs and biologicals that cannot be self-administered, but not to partial hospitalization services, as set forth in paragraph (e) of this section.
(b)General rule. Medicare Part B pays for medical and other health services furnished by providers (and not exempted under paragraph (a) of this section) only if a physician certifies the content specified in paragraph (c)(1), (c)(4) or (e)(1) of this section, as appropriate.
(c)Outpatient physical therapy and speech-language pathology services -
(1)Content of certification.
(i) The individual needs, or needed, physical therapy or speech pathology services.
(2)Timing. The initial certification must be obtained as soon as possible after the plan is established.
(i) If the plan of treatment is established by a physician, nurse practitioner, clinical nurse specialist, or physician assistant, the certification must be signed by that physician or nonphysician practitioner.
(ii) If the plan of treatment is established by a physical therapist or speech-language pathologist, the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case.
(i)Timing. Recertification is required at least every 90 days.
(ii)Content. When it is recertified, the plan or other documentation in the patient's record must indicate the continuing need for physical therapy, occupational therapy or speech-language pathology services.
(e)Partial hospitalization services: Content of certification and plan of treatment requirements -
(1)Content of certification.
(ii) The services are or were furnished while the individual was under the care of a physician.
(2)Plan of treatment requirements.
(A) The physician's diagnosis;
(B) The type, amount, duration, and frequency of the services; and
(C) The treatment goals under the plan.
(3)Recertification requirements -
(ii)Timing. The first recertification is required as of the 18th day of partial hospitalization services. Subsequent recertifications are required at intervals established by the provider, but no less frequently than every 30 days.
(iii)Content. The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the partial hospitalization program and describe the following:
(A) The patient's response to the therapeutic interventions provided by the partial hospitalization program.
(C) Treatment goals for coordination of services to facilitate discharge from the partial hospitalization program.
(f)Blood glucose testing. For each blood glucose test, the physician must certify that the test is medically necessary. A physician's standing order is not sufficient to order a series of blood glucose tests payable under the clinical laboratory fee schedule.
(g)All other covered medical and other health services furnished by providers -
(1)Content of certification. The services were medically necessary,
(2)Signature. The certificate must be signed by a physician, nurse practioner, clinical nurse specialist, or physician assistant who has knowledge of the case.
(3)Timing. The physician, nurse practioner, clinical nurse specialist, or physician assistant may provide certification at the time the services are furnished or, if services are provided on a continuing basis, either at the beginning or at the end of a series of visits.
(4)Recertification. Recertification of continued need for services is not required.
- 42 CFR 485.918 — Condition of Participation: Organization, Governance, Administration of Services, and Partial Hospitalization Services.
- 42 CFR 410.170 — Payment for Home Health Services, for Medical and Other Health Services Furnished by a Provider or an Approved ESRD Facility, and for Comprehensive Outpatient Rehabilitation Facility (CORF) Services: Conditions.
- 42 CFR 410.110 — Requirements for Coverage of Partial Hospitalization Services by CMHCs.
- 42 CFR 410.43 — Partial Hospitalization Services: Conditions and Exclusions.
- 42 CFR 485.916 — Condition of Participation: Treatment Team, Person-Centered Active Treatment Plan, and Coordination of Services.