Write the plan of care at the evaluation. Get it certified by the physician or NPP, by signature or verbal order, dated within 30 days of the first treatment day; or, since 2025, if a signed and dated referral is in the record, send the plan to the referring practitioner within 30 days of the evaluation and keep proof. Recertify at least every 90 days, sooner if the plan ends or changes significantly. Write a progress report at least every 10 treatment days and a discharge note at the end.
Work out a patient’s dates with the plan of care calculator.
Why certification matters
Medicare pays for outpatient therapy only when the patient is under the care of a physician or non-physician practitioner (NPP) and a certified plan of care is in place. The certified plan is the evidence of that physician involvement (ASHA). A missing or late certification is one of the most common and most avoidable reasons therapy claims fail review: the care can be excellent and still go unpaid. In a 2018 audit, OIG found that 61% of sampled outpatient physical therapy claims did not meet Medicare requirements (OIG).
What the plan must contain
At a minimum, the plan of care must state (CGS Medicare):
| Element | What it means | Example |
|---|---|---|
| Diagnoses | The medical and treatment diagnoses | Right total knee arthroplasty; difficulty walking |
| Long-term goals | Functional goals for the episode | Walk 500 ft in the community without a device |
| Type | The discipline and kinds of intervention | PT: therapeutic exercise, gait training, manual therapy |
| Amount | Number of sessions per day | One session a day |
| Frequency | Sessions per week | 3 times a week |
| Duration | Weeks or treatment sessions | 8 weeks |
The plan must also show the signature and professional identity (for example MD, or the therapist’s credentials) of the person who established it, and the date it was established (CGS).
A complete example
An invented patient, written the way a reviewer wants to read it:
Every element is there, the goals are measurable, and frequency and duration can be checked against the visit log.
Short-term and long-term goals
Medicare requires long-term goals in the plan. Short-term goals are not a listed element, but most clinicians add them because they make progress reports easy to write and easy to check: each report can say which short-term goals were met on the way to the long-term ones. Write both as functional, measurable outcomes (distance, assistance level, range of motion, a standardized score) with a timeframe, not as activities (“do quad sets”).
Telehealth visits
CMS says the Consolidated Appropriations Act, 2026 extended Medicare telehealth for PT, OT and speech services through December 31, 2027 (CMS). Telehealth visits sit inside the same plan of care: they count as treatment days for progress reports, and the certification and recertification rules don’t change. If you plan to mix in-person and telehealth visits, say so in the plan’s type and frequency.
Who can certify
- Physicians and NPPs (such as nurse practitioners, physician assistants and clinical nurse specialists) certify the plan.
- Podiatrists only within the scope their state allows.
- Optometrists only for low vision services.
- Chiropractors may not certify therapy plans of care.
Source: CGS Medicare.
Initial certification: 30 days
Certification is timely when it is documented by signature or verbal order and dated within the 30 days after the first day of treatment, which is usually the evaluation. A verbal certification must be followed by the practitioner’s signature within 14 days (CGS).
Example. First treatment day: Monday, March 2, 2026. The certification must be dated by April 1, 2026. If the physician gives a verbal certification on March 20, the signature is due within 14 days of that.
The 2025 referral exception
From January 1, 2025, Medicare added an exception to the initial certification requirement. It applies when a patient comes to you with a signed and dated order or referral from a physician or NPP (APTA):
- The signed, dated order or referral is in the patient’s record.
- You send the plan of care to the referring practitioner within 30 days of the initial evaluation, and the record shows that you did.
- The practitioner can sign and return it or send changes. If they do neither, their silence counts as agreement.
In September 2025 Noridian, a Medicare contractor, updated its own guidance to reflect the exception (APTA). APTA noted that as of August 2026 CMS had not yet updated chapter 15 of the Benefit Policy Manual to match, so keep an eye on your own contractor’s guidance.
Example. Dr. Lee’s signed referral for “PT eval and treat, low back pain” is scanned into the chart. The evaluation is on March 2; the clinic faxes the plan to Dr. Lee’s office on March 4 and saves the fax confirmation. No reply comes back. The initial certification requirement is met by the referral plus the documented transmission, well inside the April 1, 2026 deadline.
Documenting the transmission
The exception rests on proof that you sent the plan. A note like this, saved in the chart with the fax confirmation or portal receipt, is the kind of evidence to keep:
Direct access patients
Many states let patients see a therapist without a referral. That changes who can start care under state law, not Medicare’s payment rule: for Medicare to pay, the plan of care still needs a physician’s or NPP’s certification (CGS). Without a signed referral, the 2025 exception doesn’t apply, so send the plan for signature straight after the evaluation.
Late and delayed certification
A late certification isn’t automatically fatal. Medicare accepts a delayed certification when the physician or NPP certifies and gives a reason for the delay. Certifications made without a justification are accepted for 30 days after they were due (CGS).
Example. The physician was on leave and signs on day 41. The certification should be accompanied by a reason for the delay (for example, “Physician unavailable March 15–April 10”), and the clinic’s record should show its attempts to obtain it: dates the plan was sent and followed up.
Recertification
Recertify when a significant change to the plan is needed, and at least every 90 days after treatment starts under the plan. A physician or NPP can certify a plan for any period up to 90 calendar days (CGS). If the plan’s own duration ends before 90 days and the patient still needs care, a new or updated plan needs certifying at that point.
| Situation | Recertify by |
|---|---|
| Plan for 12 weeks, starts March 2 | May 25, 2026 (90 days comes first) |
| Plan for 8 weeks, starts March 2, care continues | April 27, 2026 (end of the plan) |
| Goals change significantly in week 4 | When the plan is changed |
- Updated objective measures against each goal.
- Which goals are met, which continue and any new ones.
- The frequency and duration for the next period, up to 90 days.
- Why continued skilled therapy is needed.
- A send date at least a week before the current certification runs out.
Progress reports
A progress report is due at least once every 10 treatment days, or at least once during each certification interval, whichever is less; the first reporting period begins on the first day of the episode, including the evaluation day (ASHA, citing the Benefit Policy Manual § 220.3). The count is by treatment days, not calendar days.
Example. A patient treated three times a week reaches treatment day 10 around the end of week 3 or early week 4; a patient treated twice a week reaches it around week 5. A missed report means every claim after day 10 is exposed until one is written.
- Objective measures compared with the last report and with the goals.
- Progress, or why progress is slower than expected.
- Any change to goals or the plan, and whether that needs a recertification.
- Why continued skilled therapy is needed.
- The clinician’s signature (a progress report is written by a clinician).
Re-evaluation vs recertification
They are different things (Noridian):
| Recertification | Re-evaluation | |
|---|---|---|
| What it is | An administrative sign-off on the plan and continued need | A clinical reassessment |
| When | At least every 90 days, or when the plan changes significantly | When there is an unanticipated change in condition or function |
| Billable? | No | Yes, when indicated (97164, 97168) |
Discharge notes
A discharge note is required. It is a progress report written by a clinician covering the period from the last progress report to discharge, including all treatment since then, and it must show the therapist reviewed the notes and agrees with the discharge (ASHA).
Work out the dates
Enter a first treatment day, treatment days so far and the plan length:
Your patient’s dates
Enter the first treatment day.
Recertify sooner if the plan of care changes significantly. If a certification is late, Medicare accepts a delayed certification with an explanation of the delay.
Runs in your browser. Dates are counted in calendar days.
Five worked cases
| Case | First day | Plan | Initial deadline | Recertify by |
|---|---|---|---|---|
| A. Standard case, physician signs | March 2, 2026 | 12 weeks | Certify by April 1, 2026 | May 25, 2026 |
| B. Signed referral on file (2025 exception) | March 2, 2026 | 8 weeks | Send plan by April 1, 2026 | April 27, 2026 |
| C. Short plan, 6 weeks | May 11, 2026 | 6 weeks | Certify by June 10, 2026 | June 22, 2026 |
| D. Long episode crossing 90 days | January 5, 2026 | 16 weeks | Certify by February 4, 2026 | April 5, 2026 |
| E. Plan starting late in the year | November 16, 2026 | 10 weeks | Certify by December 16, 2026 | January 25, 2027 |
Case A. The plan runs 12 weeks, so 90 days arrives first. The physician’s signed plan must be dated within 30 days of the first treatment day.
Case B. With a signed, dated referral in the record, the clinic meets initial certification by sending the plan to the referring practitioner within 30 days of the evaluation and keeping proof it was sent. The 8-week plan ends before 90 days, so recertification is due at its end if care continues.
Case C. A plan shorter than 90 days needs recertification at its own end date if the patient still needs care.
Case D. A 16-week plan can’t be certified for its full length: a certification covers at most 90 days, so a recertification is due by day 90.
Case E. Calendar years don’t restart the plan of care: the recertification due date runs into January as normal. (The KX threshold amounts do reset on January 1.)
A tracking workflow
- At intake: scan the referral. Is it signed and dated? Note whether the 2025 exception route applies.
- Evaluation day: write the plan with all six elements and measurable goals. Put the 30-day deadline and the 90-day (or plan-end) date in the scheduling system.
- Within 48 hours: send the plan to the physician or referring practitioner; save proof of sending.
- Day 14 and day 21: if a signature is needed and hasn’t come back, follow up and record each attempt.
- Every treatment day: the schedule shows the treatment-day count; the 10th triggers the progress report.
- Two weeks before recertification: write the progress summary that supports continued care and send the updated plan.
- Monthly: run a report of open plans with missing certifications or overdue progress reports.
Mistakes that cause denials
- Treating for weeks without chasing the signature.
- Missing an element (usually frequency or duration).
- Counting progress reports by calendar weeks instead of treatment days.
- Letting a plan run past 90 days without recertification.
- Using the 2025 exception without proof that the plan was sent.
- Billing a re-evaluation for an administrative recertification.
- No discharge note.
Related: the KX modifier and the 2026 threshold, the 8-minute rule and 2026 Medicare therapy rates.
Questions
How long does a physician have to certify a therapy plan of care?
Certification is timely when it is documented by signature or verbal order and dated within the 30 days following the first day of treatment. A verbal certification must be followed by a signature within 14 days.
Do I still need a physician signature on the plan of care in 2026?
Not always. Since January 1, 2025, a signed and dated order or referral in the record, plus evidence that the plan was sent to the referring practitioner within 30 days of the initial evaluation, can meet the initial certification requirement. If the practitioner neither signs nor sends changes, that silence counts.
Does the 2025 exception cover recertifications?
APTA’s description of the rule addresses initial certification. It does not say the exception applies to recertifications, so plan to get recertifications signed as before unless your Medicare contractor says otherwise.
How often must the plan be recertified?
At least every 90 days after treatment starts under the plan, and sooner when the plan needs significant changes or ends before 90 days and care continues.
Is a recertification billable?
No. Noridian explains that recertification is an administrative requirement and not separately billable, while a re-evaluation is a clinical service that is separately payable when it is indicated.
How often is a progress report required?
At least once every 10 treatment days, counted from the first day of the episode, including the evaluation day.
Can a chiropractor certify a therapy plan of care?
No. Physicians and non-physician practitioners certify plans; podiatrists only within their state scope, and optometrists only for low vision services.
Does the plan of care reset in January?
No. The plan of care follows its own dates. The KX threshold amounts reset on January 1, which is a separate rule.
Sources
- CGS Medicare (Part B contractor), Therapy certification and recertification requirements — the 30-day certification window, verbal orders within 14 days, delayed certification, 90-day recertification, plan contents and who can certify
- APTA, Medicare’s new exception to the plan of care certification requirement — the 2025 exception to the certification requirement and its conditions
- APTA, Noridian updates guidance on plan of care signature (October 14, 2025) — Noridian’s updated guidance on the exception (September 2025)
- ASHA, Medicare documentation requirements (citing Medicare Benefit Policy Manual, ch. 15, § 220.3) — progress reports every 10 treatment days and discharge note requirements
- Noridian Medicare, The difference between outpatient therapy recertifications and re-evaluations — the difference between recertification and re-evaluation
- CMS MLN905365, Complying with Outpatient Rehabilitation Therapy Documentation Requirements — CMS documentation requirements for outpatient therapy
- CMS, CY 2026 Therapy Services Updates — telehealth for PT, OT and SLP extended through December 31, 2027
- HHS OIG, A-05-14-00041 (March 2018) — the 2018 audit of outpatient physical therapy claims
General information about Medicare rules as of October 26, 2026, drawn from Medicare contractor, CMS and professional association sources. It is not legal or billing advice. Your Medicare contractor’s guidance and the current Benefit Policy Manual govern; check them for your situation.