Why You May Care...
Many stakeholders approach CMS each year with a request to liberalize one or another rule - be it an administrative policy, an NCD, or some other problem. While the example below is not related to molecular laboratories (my main readers), the example DOES show how multiple stakeholders coordinated - and over several years - to get a meaningful policy change at CMS.
What's It About? Physical Therapy?
Here's the status quo before 2025. A physician sees a patient who needs physical therapy. The physician writes a REFERRAL or ORDER for a physical therapy evaluation. The physical therapist spends 30 to 60 minues with the patient, doing careful tests and examples, and develops a plan of care. The PT transmits the plan of care to the physician to countersign. (This countersignature must be re-affirmed every 90 days).
Here's what people got. Beginning in January 2025, the physician issues a ORDER or REFERRAL for physical therapy. The physical therapist does the exam and prepared the report and plan of care. It's transmitted back to the referring MD. NEW RULE: As long as the physician doesn't reach out and tell the P.T. there is a problem, the P.T. can ASSUME the plan of care is OK with the physician.
While that may sound like a small change, I suspect PT stakeholders were very happy to get it.
Below I give a detailed Chat GPT summary of the rulemaking, requests, and the rationales discussed.
Find the rulemaking at 89 Fed Reg 97710, 12/9/2024, specifically 97912ff (about eight pages).
Take Home Lessons: How It Worked [Chat GPT]
Lessons learned: how stakeholders got this done
They treated the problem as a workflow failure, not just a reimbursement complaint. The argument was not simply “pay therapists more easily.” It was: the current rule forces therapists to chase duplicative signatures from busy physician/NPP offices, creating avoidable administrative waste and possible care delays. CMS explicitly acknowledged reports that therapists sometimes contacted physician offices dozens of times to obtain signatures.
They worked the issue over multiple years. CMS notes that “over the past two years” therapy-related organizations had asked the agency to reduce the administrative burden of obtaining signed plans of treatment. That signals persistence, repeated engagement, and likely multiple channels of education before the issue became rulemaking text.
They framed the change as common-sense consistency. Stakeholders pointed out that CMS already treats a signed physician/NPP order as evidence that the patient is under physician care and that therapy is medically necessary. The ask was therefore: why require a second signature on the plan of care when the physician/NPP has already ordered therapy and the therapist sends back the plan?
They gave CMS a narrow, administrable fix. They did not ask CMS to abolish physician involvement or waive plan-of-care rules wholesale. They proposed a defined exception: if there is a signed written order/referral on file and documentation that the therapist transmitted the plan of care to the physician/NPP, CMS should treat the initial certification requirement as satisfied.
They protected the agency’s oversight interests. The final policy preserves medical-necessity review, preserves recertification signatures, and does not create unlimited therapy. That made the proposal easier for CMS to accept because it reduced burden without appearing to weaken program integrity.
They showed patient benefit, not just provider convenience. The strongest argument was that waiting for a returned signature can delay therapy, potentially putting beneficiaries’ health at risk. CMS repeated that concern in the final rule, which suggests the access-to-care framing landed.
They made the burden concrete. “Administrative burden” is abstract; “therapists faxing, calling, and emailing physician offices repeatedly, sometimes more than 30 times” is vivid. That kind of operational detail helps regulators understand that the rule is producing real-world dysfunction.
They aligned multiple professional groups. CMS refers to “representatives of several therapy-related organizations” and “interested parties representing all therapy disciplines.” This mattered because the change covered PT, OT, and SLP rather than a single profession’s narrow grievance.
They anticipated implementation questions. Commenters asked CMS to clarify acceptable transmission methods, MAC instructions, effective dates, and whether recertification was included. That helped force the final rule to become operationally usable, not merely aspirational.
They accepted a partial win. CMS did not give everything stakeholders asked for. It declined to extend the exception to recertification and did not finalize a fixed 10-business-day physician modification window. But stakeholders secured the central operational reform: no second signature chase for initial certification when a signed order/referral and documented transmission are present.
What CMS changed, in plain policy terms
CMS has made a meaningful 2025 liberalization in Medicare’s outpatient therapy plan-of-care certification rules. This is not a change in who may furnish therapy, nor a waiver of medical necessity. It is a change in how the physician/NPP certification requirement is satisfied for the initial therapy plan of care when the patient already has a written physician/NPP order or referral for therapy.
The practical effect is substantial: CMS is reducing a recurrent, low-value administrative trap in which the therapist has already received a physician/NPP order for PT, OT, or SLP services, evaluates the patient, writes a plan of care, sends it back to the same physician/NPP, and then must chase a second signature to avoid denial risk. CMS now says that, in defined circumstances, the original signed order/referral can function as the physician/NPP signature for initial certification of the therapist-established treatment plan.
This is the kind of burden reduction that is both technically modest and operationally important.
Prior status quo
Under the old rule, Medicare outpatient therapy services were conditioned on a certified plan of treatment/plan of care. CMS uses “plan of treatment” and “plan of care” essentially interchangeably in this discussion. The baseline regulation at 42 CFR § 424.24(c) required a physician, nurse practitioner, physician assistant, or clinical nurse specialist with knowledge of the case to sign the initial certification for the therapy plan. CMS manual policy required the physician/NPP to sign the initial plan of care, generally within 30 days from the first day of treatment, including evaluation, or within 14 days if certification was by verbal order.
This created an odd two-step process:
The patient often arrived with a physician/NPP order or referral for therapy.
The therapist evaluated the patient and established the plan of care.
The therapist then had to send the plan back to the physician/NPP for another signature.
If the physician/NPP did not return the signed plan, the therapist faced payment risk, even though the physician/NPP had already ordered the therapy.
CMS explicitly recognized the operational problem. Therapy organizations told CMS that therapists sometimes made exhaustive efforts to obtain signatures from busy physician offices, including repeated phone, email, and fax follow-up. If the signature did not come back, the therapist might not meet Medicare payment conditions despite furnishing otherwise appropriate care. CMS also acknowledged that care could be delayed because therapists were reluctant to begin treatment while waiting for a signature that might not return.
In short: the old system converted a physician’s clinical referral into a paperwork vulnerability.
The 2025 change
CMS finalized a new exception at 42 CFR § 424.24(c)(5). For dates of service on and after January 1, 2025, where the patient has a written, signed, and dated order or referral from a physician, NP, PA, or CNS for outpatient PT, OT, or SLP, CMS and its contractors may treat that order/referral signature as equivalent to the physician/NPP signature on the initial therapy plan of treatment, provided the therapist documents that the plan was transmitted to the physician/NPP within 30 days of the initial evaluation.
CMS was careful not to call this merely a “presumption.” Instead, it framed the policy as treating the physician/NPP signature on the order/referral as satisfying the initial certification requirement when the required documentation is present. That is a stronger policy position than saying contractors may loosely infer approval.
The new rule applies to:
Physical therapy, occupational therapy, and speech-language pathology.
The physician/NPP order or referral must:
Be written.
Be signed and dated.
Identify the type of therapy needed: PT, OT, or SLP.
Be maintained in the patient’s medical record.
Include enough information to identify the beneficiary and the ordering/referring physician/NPP.
Be paired with evidence that the therapist transmitted the plan of care/treatment to the ordering/referring physician/NPP within 30 days of the therapist’s initial evaluation.
CMS did not establish a closed list of acceptable transmission methods. It indicated that MACs should continue accepting the kinds of delivery documentation they have accepted historically, such as fax logs, EHR timestamps, electronic transmission records, call logs, tracking forms, paper logs, or other records showing that the plan was sent.
What did not change
This is important because CMS did not create open-ended “direct access equals automatic Medicare payment.”
First, CMS did not require a physician/NPP order or referral as a condition for all outpatient therapy. CMS states that references to an order/referral in the new exception should not be construed to create a general order/referral requirement for outpatient PT, OT, or SLP.
Second, if there is no written physician/NPP order or referral, then the old initial certification signature requirement still applies. The therapist-established plan still needs the physician/NPP signature for initial certification.
Third, CMS did not extend this exception to recertifications. Recertification remains governed by the existing rule: at least every 90 days, the physician/NPP must recertify the continuing need for therapy by signing the medical record. CMS explicitly declined to create an order/referral-based substitute for recertification, because it wanted to avoid open-ended therapy without periodic physician/NPP sign-off.
Fourth, the change does not guarantee payment. MACs retain authority to determine whether services are reasonable and necessary. CMS emphasized that the physician/NPP signature—whether on the order/referral or on the plan of care—does not itself prove medical necessity. It proves the physician/NPP’s intent for skilled therapy and supports the statutory “under the care of a physician” requirement, but the actual services and documentation must still support coverage.
Why this matters operationally
This is a significant burden reduction because it attacks a familiar Medicare pathology: duplicative documentation that satisfies form rather than clinical substance.
In many cases, the physician/NPP has already made the clinically relevant decision: the patient needs therapy. The therapist then performs the actual therapy evaluation and writes the plan. Under the old system, payment risk could turn not on the therapist’s evaluation, medical necessity, or patient outcomes, but on whether a separate signature was returned from a physician office that might be overwhelmed with administrative traffic.
CMS’s final policy reduces burden in several ways:
For therapists, it reduces the need to repeatedly chase signatures and reduces the risk that payment will be denied solely because a referring clinician did not return a signed plan of care.
For physicians and NPPs, it reduces duplicative signing of paperwork where their original order/referral already documented the clinical intent.
For patients, it should reduce delays in beginning therapy, especially when therapists previously hesitated to start treatment before securing the returned signature.
For MACs and reviewers, it should reduce signature-only denials while preserving the ability to review medical necessity.
This is why the change is more than clerical. It changes the operational default from “no returned plan signature, no safe payment pathway” to “signed order/referral plus timely documented transmission of the therapist’s plan can satisfy initial certification.”
The policy balance CMS is striking
CMS is trying to preserve three statutory/regulatory ideas while removing unnecessary friction:
The patient must be under the care of a physician/NPP.
The patient must need skilled therapy.
Therapy must be furnished under a therapist-established plan of care that is communicated to the ordering/referring clinician.
The old rule tried to enforce those principles through a second physician/NPP signature. The new rule says, in effect: when the physician/NPP already signed and dated an order/referral for the therapy type, and the therapist promptly sends back the treatment plan, Medicare can treat that as satisfying initial certification.
That is a classic regulatory burden-reduction move: retain the substantive safeguard, eliminate a duplicative ritual.
A practical “new rules” checklist
For an initial PT/OT/SLP episode beginning January 1, 2025 or later:
If there is a written physician/NPP order or referral:
The therapist may rely on the new exception if the record contains the signed and dated order/referral, the order/referral identifies the therapy type, and the therapist documents that the plan of treatment was sent to the ordering/referring physician/NPP within 30 days of the initial evaluation.
If the physician/NPP later returns the signed plan:
Fine. Then the ordinary signature requirement is satisfied directly.
If the physician/NPP does not return the signed plan:
The signature on the written order/referral can substitute for the initial certification signature, assuming the documentation conditions are met.
If there is no order/referral:
The therapist still needs the physician/NPP signature on the initial plan of care.
For recertification:
The physician/NPP signature is still required. The new exception does not apply.
For medical necessity:
Nothing is waived. Documentation must still support that the services were reasonable and necessary.
Bottom line
CMS has liberalized the Medicare outpatient therapy plan-of-care approval process by allowing a signed and dated physician/NPP order or referral to substitute for a separate physician/NPP signature on the initial therapist-established plan of care, so long as the plan is transmitted to the physician/NPP within 30 days of the initial evaluation and the record supports the required elements.
This is a meaningful, patient-facing and provider-facing burden reduction. It does not eliminate physician/NPP involvement, recertification, or medical-necessity review. But it does remove a duplicative signature chase that could delay care and create denial risk without adding much clinical value.
