MLN905365 - Complying with Outpatient Rehabilitation Therapy Documentation Requirements
Starting January 1, 2025, we allow the physician or non-physician practitioner (NPP) written order or referral to substitute for the signature on the initial plan of care (POC) certification.
This fact sheet describes common ComprehensiveError Rate Testing (CERT) Program errors related to medical record documentation. It’s designed to help providers understand how to submit accurate and supporting documentation for outpatient rehabilitation therapy services.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: September 01, 2025
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.