Your patient would be most appropriate for a:
Medicare B Restorative (Rehabilitative) Plan of Care
To recap, for Medicare B to cover restorative (or rehabilitative) therapy, the following criteria must be met:
Medically Indicated:
Therapy must be required to address the patient’s medical condition.
Spontaneous recovery is not expected to match the level of improvement that can be achieved with skilled therapeutic intervention.
Reasonable and Necessary:
The therapy must be appropriate for the patient’s condition and not excessive.
There should be a reasonable expectation of significant improvement in the patient’s functional ability within a predictable period of time.
The treatment should align with accepted standards of practice.
Requires the Skills of a Clinician:
The therapy must require the skills of a licensed therapist.
The services cannot be safely and effectively performed by non-skilled personnel or by the patient themselves.
Certification Requirements
Please be aware that any patient on a Medicare B Restorative Plan of Care MUST be under the care of either a Physician (Doctor of medicine or osteopathy) or a Non-Physician Practitioner (nurse practitioner, clinical nurse specialist, or physician assistants) who is willing to either provide a referral or sign the Initial Plan of Care and any future revisions to the plan of care that require recertification.
Changes for 2025: The CMS 2025 Medicare Physician Fee Schedule final rule introduced significant changes for physical therapy, particularly related to the plans of care requirement. For the plan of care, CMS has removed the requirement for physical therapists to obtain a referring physician's signature within 30 days of initiating care IF A REFERRAL FOR THERAPY INITIATED THE PLAN OF CARE. In these scenarios, therapists need to submit the plan of care to the referring physician within 30 days, but do not need this plan of care signed and certified. NOTE: If treat in a Direct Access state, and you are seeing your patient WITHOUT a referral on file, you are still required to have your Initial Plan of Care signed and returned within 30 days.
For more information related to Medicare B Plan of Care Certification, refer to the Medicare Policy Manual Chapter 15, Section 220.1.3, Certification and Recertification of Need for Treatment and Therapy Plans of Care.
Clinical Reassessments:
With a patient on a Medicare B Restorative Plan of Care, you are required to complete a reassessment at the following points in care:
At or before every 10th visit.
If, and when, there is a change in clinical status requiring reassessment and revision of the patient’s treatment goals and interventions.
If you require additional visits beyond what was initially certified in the Initial Plan of Care.
When you complete your reassessment, you need to consider the same questions you did during your Initial Evaluation to determine whether they qualify for continued skilled care AND if should remain on a Restorative Plan of Care OR transition to a Maintenance Plan of Care. Choose the Back button below to go back to the starting page.