Medicare PT certification: when a referral replaces a plan signature

The exception changes the signature requirement, not the need for certification or a treatment plan. It does not guarantee payment.

The unsigned plan is only one part of the record

Consider this hypothetical clinic situation.

Your biller opens a therapist's initial plan of care. The physician's signature line is blank, so another signature request goes onto tomorrow's list.

The referral folder contains a signed, dated order for physical therapy. Elsewhere, the clinic has a transmission record for the plan. Nobody has checked which plan was sent, who received it, or when the initial evaluation was completed.

Two different problems could be hiding behind that blank signature line. The record might support the initial signature exception. Or the clinic might have an order without the delivery evidence needed to use it.

Sending another request treats both records the same. Reviewing the referral, plan, and delivery evidence tells the biller which question still needs an answer.

What the initial signature exception requires

The Code of Federal Regulations (CFR) contains the rule at 42 CFR 424.24(c)(5).

For a therapist-established plan, the patient's record must contain a written order or referral from the patient's physician or an eligible nonphysician practitioner. Here, that means a nurse practitioner, physician assistant, or clinical nurse specialist.

The therapist must have documented evidence that the plan was delivered to that practitioner within 30 days of completion of the initial evaluation.

The Centers for Medicare & Medicaid Services (CMS) also explains what the order or referral must contain. It must be written, signed, dated, and identify the type of therapy needed. CMS expects information identifying the patient and the ordering or referring practitioner.

Those details come from CMS's final-rule explanation, not from a suggested clinic template.

The exception took effect for dates of service on or after January 1, 2025, based on the initial evaluation date. It is not a new 2026 exception. See CMS's effective-date explanation.

When these conditions are met, the initial certification does not require a separate physician or eligible practitioner's signature on the therapist-established plan. The referral alone is not enough.

Start the delivery clock at the evaluation

Use the date the initial evaluation was completed. Do not start this 30-day window at the referral date, the next treatment visit, or the latest signature request.

That distinction matters when an evaluation and later treatment visits fall on different dates. A later appointment does not move the deadline in this exception.

CMS separately requires initial certification as soon as possible after the plan is established. The 30-day delivery window is not a recommendation to wait. Both requirements appear in the certification regulation.

If you discover missing or late evidence, do not backdate a record or assume another fax repairs the original timeline. Have the clinic's billing or compliance lead review the available certification route and applicable contractor guidance.

Separate the records before choosing the next action

This table is a clinic review aid, not a Medicare claim-approval tool. It assumes an initial plan established by the therapist unless the row says otherwise.

The first three rows follow the regulation's signature and treatment-plan provisions. The fourth is our practical recommendation for checking evidence. The recertification boundary is addressed below.

Keep delivery evidence, not another empty checkbox

The regulation uses the word "delivered." CMS's final-rule explanation also describes the plan as transmitted or submitted to the ordering or referring practitioner.

That does not turn a queued fax into a completed transmission. It also does not create a separate requirement to obtain a physician read receipt.

CMS says it has not established a comprehensive list of acceptable delivery methods. Do not present one software status or file format as a universal Medicare standard.

Our recommendation is to keep the evidence with the plan it supports. A fax result or secure-message record may help show what happened. Review what the record actually establishes and your Medicare contractor's instructions.

A short clinic review card could record:

• The initial evaluation completion date.
• The signed, dated referral and the practitioner who issued it.
• The actual plan sent to that practitioner.
• The delivery date and location of supporting evidence.
• Any unresolved question, who owns it, and the next certification action.

These are suggested review fields, not a CMS-mandated form. Use the clinic's approved record system and communication channels. Do not move patient documents into a public worksheet.

Recertification still needs a signature

The exception is limited to initial certification.

Under 42 CFR 424.24(c)(4), recertification is required at least every 90 days. The record must show the continuing need for therapy. The reviewing physician or eligible nonphysician practitioner must recertify by signing the medical record.

CMS expressly states that the initial exception does not create a signature exception for recertification.

Do not turn "initial certification resolved" into "no more certification work this episode." Nor does the 90-day interval promise 90 days of covered care.

Keep this administrative review separate from deciding which home exercises a patient should follow. A covering-therapist handoff answers a different question. So does the home plan provided at discharge.

What this exception does not decide

No written referral in the record means the usual plan-signature route remains. It does not mean Medicare created a universal referral requirement for outpatient therapy. The regulation explicitly rejects that interpretation.

This article addresses Original Medicare outpatient PT in private practice. It does not resolve state direct-access rules, Medicare Advantage plan procedures, home health, or comprehensive outpatient rehabilitation facility requirements.

It also does not establish medical necessity or approve an individual claim. CMS explains that neither a referral signature nor a plan signature ensures payment.

The useful change is narrower: review the complete initial certification record before chasing a signature that may not be required.

HepBuddy is web-based home-exercise software. The certification records discussed here belong in the clinic's own documentation process. Home-exercise software is not a substitute for that review.

Sources checked November 1, 2026. The retrieved electronic Code of Federal Regulations (eCFR) text was current through October 29, 2026. This is a general explanation of published policy, not legal advice or a determination about an individual claim.