Medicare outpatient therapy plans of care: who establishes, certifies, and recertifies

For Medicare outpatient therapy, PT, OT, and SLP services must relate to a written plan of care established before treatment begins. The plan may be established by a physician or nonphysician practitioner (NPP), or by the physical therapist, occupational therapist, or speech-language pathologist who will provide the services. At minimum it must contain diagnoses, long-term treatment goals, and the type, amount, duration, and frequency of therapy. A physician or NPP certifies the plan. CMS’s manual says initial certification is timely within 30 days of the first treatment, and that recertification is due at least every 90 days or when the plan changes significantly. These are outpatient rules. Skilled nursing facility, home health, and inpatient rehabilitation rules are separate.

Quoted from official pages checked November 10, 2026. Confirm current requirements, fees, and dates on those sites. This page is not legal advice and does not guarantee eligibility, certification, or licensure.

The Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services; table of contents Rev. 13889, issued July 30, 2026) was read on November 10, 2026. Section 220.1.2 carries Rev. 255 and section 220.1.3 carries Rev. 88. The regulation 42 CFR 410.61 was read on eCFR (up to date as of November 6, 2026).

Which settings this covers

Section 220 of Chapter 15 covers outpatient physical therapy, occupational therapy, and speech-language pathology under Part B. The manual says that where a setting has its own rules, “it takes precedence over these general outpatient policies”, and points to Chapter 8 for SNFs and Chapter 7 for home health. Those chapters are not summarized here. For inpatient rehabilitation, see working in inpatient rehabilitation.

Establishing the plan

Section 220.1.2 states: “The services must relate directly and specifically to a written treatment plan as described in this chapter. The plan, (also known as a plan of care or plan of treatment) must be established before treatment is begun.” It states: “The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded with the plan.”

The manual lists who may establish it: a physician/NPP, “The physical therapist who will provide the physical therapy services;”, “The occupational therapist who will provide the occupational therapy services; or”, and “The speech-language pathologist who will provide the speech-language pathology services.” The regulation, 42 CFR 410.61(b), lists a physician, the physical therapist, the speech-language pathologist, or the occupational therapist who furnishes the services, and “A nurse practitioner, a clinical nurse specialist, or a physician assistant.”

The manual also states: “Establishing the plan, which is described below, is not the same as certifying the plan”. And: “Payment for services provided before a plan is established may be denied.”

What the plan must contain

The manual states: “The plan of care shall contain, at minimum, the following information as required by regulation” It lists “Diagnoses;”, “Long term treatment goals; and”, and “Type, amount, duration and frequency of therapy services.” 42 CFR 410.61(c) states that the plan “prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.”

On disciplines, the manual states: “There shall be different plans of care for each type of therapy discipline.” It gives an example: “For example, a physical therapist may not provide services under an occupational therapist plan of care.”

Changing the plan

The manual states that changes “are made in writing in the patient’s record and signed by one of the following professionals responsible for the patient’s care:” It lists the physician/NPP, the treating physical therapist, speech-language pathologist, or occupational therapist for their own discipline, and a registered professional nurse or physician/NPP on staff acting on oral orders. It also states: “While the physician/NPP may change a plan of treatment established by the therapist providing such services, the therapist may not significantly alter a plan of treatment established or certified by a physician/NPP without their documented written or verbal approval”.

Certification

Section 220.1.3 states: “Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.” On the first certification, it states: “Timely certification of the initial plan is met when physician/NPP certification of the plan is documented, by signature or verbal order, and dated in the 30 days following the first day of treatment (including evaluation).” It adds: “If the order to certify is verbal, it must be followed within 14 days by a signature to be timely.”

Recertification

The manual states: “Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed.” It also states: “A physician/NPP may certify or recertify a plan for whatever duration of treatment the physician/NPP determines is appropriate, up to a maximum of 90 calendar days.” And: “Recertification is not required if the duration of the initially certified plan of care is more than the duration (length) of the entire episode of treatment.”

Delayed certification

The manual states: “Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay.” It also states: “It is not intended that needed therapy be stopped or denied when certification is delayed.”

A note on the sources

The manual’s list of who may establish a plan says “physician/NPP”, and the regulation names nurse practitioners, clinical nurse specialists, and physician assistants. The manual’s plan-content text also still mentions functional reporting G-codes, with a note that functional reporting no longer applies to dates of service on and after January 1, 2019. This page quotes both sources as written and does not reconcile them. Medicare Administrative Contractors apply these rules; ask yours about a specific claim.

What this page does not do

It gives no payment rates, fee schedule amounts, therapy thresholds, KX modifier amounts, or billing codes. It is not legal, billing, or compliance advice. Confirm current rules with the agency that publishes them, your employer, and your state board.