New Recertification Requirement

Have your clinicians been complying with Change Request 9189 of the Program Integrity Manual (Pub 100-08) involving a new certification requirement that applies to recertifications? This update requires a statement on the recertification certification/plan of care by the certifying physician estimating how much longer skilled services will be required. This statement is part of the certification for continued services and must be signed by the physician.

While the statement may be documented by the agency within the plan of care, there should be evidence in the clinical record that serves as evidence of the discussion between the agency and the physician regarding the estimation of how much longer the skilled services will be required. Although the agency may complete the expected length of service for the physician to sign, the time frame must be based on the physician’s estimate; not the agency’s estimate. The estimate provided can be longer than 60 days; however, this date will need to be reviewed and updated with the next recertification.

To meet this requirement, an actual statement must be included in the plan of care. The agency cannot simply use the duration of physician orders as the estimate. CMS does not mandate where the statement is placed; however, it should appear either within the certifying statement or on the plan of care that is signed by the certifying physician.

Check out our new job aid on the Recertification Process that reviews general requirements of recertification, as well as this new coverage mandate.

Recert Process Job Aid