The physical therapy plan of care under Medicare: contents, certification and changes

A physical therapy plan of care under Medicare Part B is the written plan that outpatient therapy must follow, and it has to be in place before treatment starts. At minimum it names the diagnoses and the long-term goals, and sets out the therapy: its type, how much per day, how many times a week, and for how long. A physician or nonphysician practitioner (NPP) then certifies it. The CMS manual treats that signature as timely within 30 days of the first treatment day (the evaluation counts as one), and wants recertification at least every 90 days, or sooner if the plan changes significantly.

Since January 1, 2025, the federal regulation also lets the initial certification stand without that signature when a written order or referral is on file and you can show the plan was delivered within 30 days of the initial evaluation. Recertification still needs one.

This is about Original Medicare Part B only, in the US. The quotes come from the Medicare Benefit Policy Manual (sections 220.1 to 220.1.3 and 220.3 of Chapter 15), and from the two regulations behind it, 42 CFR 424.24(c) and 42 CFR 410.61; revision dates are in the reference list. It is education, not billing or legal advice. The rules change, and the manual does not always keep pace with the regulation, so check the current manual and ask your Medicare Administrative Contractor (MAC) before you change how you work.

What is a physical therapy plan of care under Medicare?

The regulation is short. 42 CFR 410.61(a) says outpatient rehabilitation services, including those from a therapist in private practice, "must be furnished under a written plan of treatment". Section 220.1.2 of the manual treats plan of care and plan of treatment as the same thing and says the plan "must be established before treatment is begun." A plan counts as established when it is developed, written or dictated.

Who can establish it? Under 410.61(b), the physical therapist who furnishes the PT services, a physician, or a nurse practitioner, clinical nurse specialist or physician assistant. The manual has one exception. In a CORF, a separate type of Medicare outpatient rehab facility, only a physician may establish the plan.

The manual draws a line you will see repeated: "Establishing the plan, which is described below, is not the same as certifying the plan". You, as the PT, usually establish it. The physician or NPP certifies it. The plan must also carry "the signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established".

Evaluation and first treatment can fall on the same day, and both are billable. The manual adds that "Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who establishes the plan." It also warns that "Payment for services provided before a plan is established may be denied."

What must a Medicare plan of care contain?

Section 220.1.2 lists the minimum:

• "Diagnoses;"
• "Long term treatment goals; and"
• "Type, amount, duration and frequency of therapy services."

The regulation says much the same in one sentence. Under 410.61(c), 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."

The manual defines each term, and the defaults matter if you leave one out:

Element	What the manual says	If you leave it out
Type	PT, OT or SLP, or a specific treatment or intervention	For a single evaluation, assumed to match the discipline ordered or the therapist who evaluated
Amount	"the number of times in a day the type of treatment will be provided"	One session a day is assumed
Frequency	"the number of times in a week the type of treatment is provided"	One treatment is assumed
Duration	The number of weeks, or the number of treatment sessions, for this plan of care	No default is given
Goals	Long-term goals covering the whole episode of care in this setting	Required, so there is no default

For goals, the manual says they "should be measurable and pertain to identified functional impairments." Short-term goals are optional in the plan, and for a very short episode, "therapy is expected to be completed in 4 to 6 treatment days", the long-term and short-term goals may be the same. The SMART goals guide shows how to write goals that pass that test.

A few more rules from the same section trip people up. The plan "shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan." Each discipline needs its own plan with its own diagnosis and goals, and the manual states plainly that "a physical therapist may not provide services under an occupational therapist plan of care." Two plans for two conditions from two referring physicians are acceptable, and so is one combined plan if one physician will certify both.

Tapered frequency

You do not have to predict every visit. When you plan to taper, the manual says the beginning and end frequencies are planned, and gives this wording as an example: "once daily, 3 times a week tapered to once a week over 6 weeks". Changes to frequency made on clinical judgment do not need recertification unless the physician or NPP asks for it.

Optional extras

The listed contents are the minimum for payment. The manual expects many clinicians to write more, such as short-term goals or the specific interventions and how much of each, and recommends noting the plan's start date. If your templates still carry functional reporting G-codes, the manual notes that functional reporting stopped applying to dates of service from January 1, 2019.

Who certifies the plan of care, and when?

Certification is the physician's or NPP's approval of your plan. Section 220.1.3 says "Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care." In certifying, the practitioner confirms the three conditions in 42 CFR 424.24(c)(1): the patient needs therapy, is under the care of a physician, NP, clinical nurse specialist or physician assistant, and is being treated under a plan that meets 410.61.

An order is not the same thing. Section 220.1.1 says "Although there is no Medicare requirement for an order, when documented in the medical record, an order provides evidence that the patient both needs therapy services and is under the care of a physician." Payment depends on certification of the plan, not on the order. If a signed order already contains a plan with the required contents, no further certification is needed.

Not every practitioner can certify. The manual states that "Chiropractors may not certify or recertify plans of care for therapy services." Podiatrists must stay within their state scope, and optometrists may order and certify only low vision services. When you, the PT, establish the plan, 424.24(c)(3)(ii) says the certification must be signed by a physician, NP, CNS or PA "who has knowledge of the case", except in the situation described under the 2025 change below.

The 30-day rule for initial certification

The regulation says only that "The initial certification must be obtained as soon as possible after the plan is established." The 30 days come from the manual, which defines "as soon as possible" this way: "the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment."

It then spells out what timely looks like: "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)." A verbal order counts only if a signature follows: "If the order to certify is verbal, it must be followed within 14 days by a signature to be timely." Make a dated note of the verbal order in the record.

Send the plan to the physician as soon as you write it. The manual says the therapist should forward it straight away, and that "Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification."

Once signed, the initial certification covers the plan "for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less." The initial treatment includes the evaluation that produced the plan.

The 2025 change: an order on file and the plan delivered within 30 days

The regulation now has a paragraph the manual does not yet describe. 42 CFR 424.24(c)(5) was added by the CY 2025 Physician Fee Schedule final rule, effective January 1, 2025. It reads, in part: "If the plan of treatment is established by a physical therapist, occupational therapist, or speech-language pathologist, and there is a written order or referral from the individual's physician, nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS) in the patient's record and the therapist has documented evidence that the plan of treatment has been delivered to the physician, NP, PA, or CNS within 30 days of completion of the initial evaluation, the certification does not need to be signed by a physician, NP, CNS, or PA who has knowledge of the case."

Without a written order or referral in the record, the same paragraph says you still need the practitioner's signature on the plan under (c)(3). It closes with a line relevant to direct access: "No references to an order or referral in this subsection shall be construed to require an order or referral for outpatient physical therapy, occupational therapy, or speech-language pathology services."

The explanatory text of the final rule fills in some gaps. The order or referral must be in writing, and the physician or NPP must have signed and dated it. It has to name the type of therapy (PT, OT or SLP), and CMS expects it to identify the patient and the practitioner. The exception applies from January 1, 2025, based on the date of your initial evaluation.

It covers the initial certification only: CMS stated that it did not propose, and does not intend, an exception for recertification, and (c)(4) still says the reviewing practitioner "must recertify the plan by signing the medical record." It does not apply to CORFs, where a physician must establish the plan. And it does not change medical review: CMS said the policy "will not affect a contractor's ability or authority to determine whether therapy services are reasonable and necessary".

Two details catch people out. The 30 days in (c)(5) run from completion of the initial evaluation, while the manual's timeliness rule counts from the first day of treatment, so the two are not worded the same. CMS also said it would revise the manual, but at the time of writing section 220.1.3 still carries its 2008 revision and does not mention the exception.

Ask your MAC how it applies the rule, and keep a record of when and how each plan was delivered. At least one MAC has put its reading in writing. Noridian's Jurisdiction F Part B page on therapy certification (last updated September 8, 2025) asks for "a signed and dated order" and "one-time transmission of the plan of care to the referring provider within 30 days of initial treatment". Sending the plan the day you write it meets both that wording and the regulation's. CMS gave no list of accepted delivery methods and said contractors would keep accepting the methods they accepted before.

Delayed certification

A late signature does not automatically sink the claim. Section 220.1.3 says "Certifications are acceptable without justification for 30 days after they are due." After that, a delayed certification is accepted when the physician or NPP signs it with a reason for the delay, such as a plan that was never signed or an original that was lost. For delays over 6 months, you may add other evidence that a physician was involved, such as an order, notes, phone contact or requests for certification.

The manual also says "It is not intended that needed therapy be stopped or denied when certification is delayed." What it will not accept is a certification signed long after the fact by someone with no sign of involvement. Its example is a signature 2 years after treatment from a physician who had no knowledge of the patient, with nothing in the record to show a physician was part of the case.

If no certification can be produced for the dates billed, the denial is a technical denial, and it is overturned if an appropriate certification turns up later. Who pays in the meantime depends on your setting. Under a provider agreement, the provider cannot charge the patient. For a supplier, such as a therapist in private practice, the manual says a technical denial for missing certification "results in beneficiary liability", and it recommends telling the patient about the need for certification and what happens without it.

Recertification at least every 90 days

The regulation is direct: "Recertification is required at least every 90 days." At recertification, the plan or other record must show the continuing need for therapy, and the reviewing practitioner signs the medical record.

The manual adds when it should happen. "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." A physician or NPP can certify any length up to 90 calendar days, and the manual expects the certified length to match the patient's likely episode, even when that is less than 90 days.

Treatment beyond the certified duration needs a recertification for the extra time. If the whole episode fits inside the first certified plan, no recertification is needed. The recertifying practitioner does not have to be the one who signed the first plan. A physician can also certify only up to the date of a visit they want the patient to attend, and services after that date are not covered until the plan is certified again.

What happens when the plan of care changes?

Any change goes in writing in the patient's record, signed by one of the professionals listed in 410.61(d), which include the treating PT and the physician or NPP. The regulation adds that "The changes are incorporated in the plan immediately."

Whether the physician signs again comes down to how big the change is. The manual says "A change in long-term goals, (for example if a new condition was to be treated) would be a significant change." For those, "Physician/NPP certification of the significantly modified plan of care shall be obtained within 30 days of the initial therapy treatment under the revised plan." You may not significantly alter a plan a physician established or certified without their documented approval.

Smaller changes do not need a new signature. The manual's examples of insignificant changes are frequency or duration changed because the patient is ill, and short-term goals adjusted as the patient progresses toward the same long-term goals. It also says "Procedures (e.g., neuromuscular reeducation) and modalities (e.g., ultrasound) are not goals, but are the means by which long and short term goals are obtained." Changing them as the patient progresses, or because one is not working, needs no physician signature while the goals stay the same.

You can also drop an intervention before the physician approves it, if the patient met the goal or did not respond to it. Report that to the physician or NPP before the next certification.

How the plan of care fits with evaluation, progress reports and notes

When a contractor asks for records, section 220.3 lists what it will expect to see: the evaluation and plan of care; the certification and any recertifications; progress reports and discharge notes; and a treatment note for every treatment day. If a patient needs more care than is usual for the condition, you can add a separate statement explaining why. The manual does not require one when the record already shows the need. Once a patient passes the annual therapy threshold, this starts to matter more, as the KX modifier guide explains.

The evaluation

The evaluation and plan can be one document or two. The evaluation should show why a course of therapy is needed, through objective findings and what the patient reports. It includes the diagnosis and the conditions and complexities that affect treatment. Then it gives either a finding that treatment is not needed, or a prognosis with an expected time frame and a plan of care. Section 220.3 recommends objective measures at the start of treatment and during or after it to show progress, and the outcome measures guide covers how to choose and repeat them.

Progress reports every 10 treatment days

"The minimum progress report period shall be at least once every 10 treatment days." The first reporting period starts on the first day of the episode, whether that day was an evaluation or a treatment. Days the patient is not seen for treatment, evaluation or re-evaluation are not counted. The report must be written by the clinician, meaning the PT, not an assistant, and a late one has to be written within 7 calendar days of the end of the period.

Progress reports and recertification run on separate clocks. The manual says "the dates for recertification of plans of care do not affect the dates for required progress reports", and one recertification period may contain several reports. A PT's report includes an assessment of progress toward each goal, plans for continuing treatment, and any changes to goals, discharge, or an updated plan sent for certification of the next interval.

The report is also where short-term goals move. "Since only long term goals are required in the plan of care, the progress report may be used to add, change or delete short term goals." A report written by the PT does not need a physician signature on its own. A revised plan sent with it goes to the physician or NPP for recertification, and section 220.1.2 C sets out which changes need it.

Treatment notes and discharge

Every treatment day needs a note with the date, each intervention provided and billed, total timed code minutes and total treatment time, and your signature and credentials. The 8-minute rule guide explains the timed minutes, and the SOAP notes guide shows one way to lay out the note. "The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment", and the manual calls it the last chance to justify the medical necessity of the whole episode.

The home exercise program and the plan of care

The manual sections quoted here do not use the words home exercise program, but they point at it more than once. Section 220.1.2 describes tapering visits as the patient moves toward "an independent or caregiver assisted self-management program". Section 220.1.3 notes that some patients are discharged early because they "were successfully progressed to an independent home program."

It also affects what goes in your notes. Section 220.3 says "Specifics such as number of repetitions of an exercise and other details included in the plan of care need not be repeated in the treatment notes unless they are changed from the plan." When you do change the program, record it, because "New exercises added or changes made to the exercise program help justify that the services are skilled." The manual is talking about the exercise program in treatment, but the same habit suits the home program: note each change and the reason for it. Choosing and dosing the exercises is covered in the home exercise program guide.

PocketPhysio holds that program for you. Choose what goes in, put a dose on every exercise (sets, reps, hold) and type the cue you would say out loud in the room. It reaches the patient's phone by SMS, email or a link, or through Pocket Physio Care, the app for patients, and WhatsApp is another route. Each exercise plays as a video while a spoken guide talks the patient through it. When they return, last visit's program is open and ready to progress.

A worked example

Mrs. L is made up, and so are her dates. The example shows the order things happen in, not the amount of therapy any real patient should get.

Mrs. L, 72, comes to your private practice with a signed and dated written referral from her physician for physical therapy for knee osteoarthritis. On day 1 you evaluate her and write the plan: the diagnosis, two long-term goals (standing up from a dining chair without her hands, and walking to the end of her street and back), and PT twice a week for 8 weeks. You send the plan to her physician that afternoon and record how and when it went.

1. Certification. Under the manual, a signature dated within 30 days of day 1 is timely. Because the referral is on file and you have evidence the plan was delivered within 30 days of the evaluation, 424.24(c)(5) says the certification does not need that signature. Check how your MAC handles this before relying on it.
2. Duration. Eight weeks is under 90 days, so this one certification covers the plan unless it runs longer.
3. Progress reports. At twice a week, with day 1 counted, the 10th treatment day falls in week 5. You write a report by then and may write them more often.
4. A small change. In week 3 she is ill and misses the week. You change the frequency for that week and adjust a short-term goal. Both are insignificant changes, so no new signature is needed. Missed days are not treatment days, so her 10th treatment day moves to week 6.
5. A big change. In week 6 she asks you to treat new shoulder pain as well. That adds a long-term goal, which is a significant change, so the revised plan needs certification within 30 days of the first treatment under it. The referral on file was for her knee, so get the revised plan signed.
6. Discharge. By week 8 she meets both knee goals: she can stand up from a chair without her hands, and walk to the end of her street and back. You discharge her with a home program and a discharge note.

Common mistakes with the Medicare plan of care

1. Treating before a plan exists, when the treating clinician is not the one who will establish it.
2. Leaving amount, frequency or duration off the plan and getting the manual's defaults instead.
3. Goals that cannot be measured, or that do not relate to a functional impairment.
4. Sending the plan to the physician days after it was written, with no record of when it went.
5. Accepting a verbal certification and never getting the signature within 14 days.
6. Assuming the 2025 change removes every signature. It covers only the initial certification, only when a signed and dated written order or referral is on file, and never recertification.
7. Treating past the certified duration or the 90-day mark without a recertification.
8. Adding a new condition or long-term goal without getting the revised plan certified.
9. Mixing up the progress report clock with the recertification clock.
10. Asking a chiropractor to certify a PT plan.

The short version

A Medicare physical therapy plan of care must be in place before treatment. It names the diagnoses and long-term goals, plus the type of therapy with its amount and frequency, and how many weeks or sessions the plan lasts. A physician or NPP certifies it, and the manual counts that as timely within 30 days of the first treatment day.

Since January 1, 2025, 42 CFR 424.24(c)(5) removes the need for that signature on the initial certification when a written order or referral is on file and the plan was delivered within 30 days of the evaluation. Recertify, with a signature, at least every 90 days, and whenever a significant change such as a new long-term goal comes up. Progress reports keep their own clock: at least once every 10 treatment days. Rules change, so check the current manual and your MAC.

References

1. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual (Publication 100-02), Chapter 15: Covered Medical and Other Health Services (table of contents Revision 13889, issued July 30, 2026). Section 220.1, Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services (Revision 255, effective January 1, 2019); section 220.1.1, Care of a Physician/Nonphysician Practitioner (NPP) (Revision 179, effective January 7, 2014); section 220.1.2, Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services (Revision 255, effective January 1, 2019); section 220.1.3, Certification and Recertification of Need for Treatment and Therapy Plans of Care (Revision 88, effective January 1, 2008); section 220.3, Documentation Requirements for Therapy Services (Revision 255, effective January 1, 2019). Accessed September 28, 2026. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
2. Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B, paragraph (c), Outpatient physical therapy, occupational therapy, and speech-language pathology services (as amended at 89 FR 98565, Dec. 9, 2024). Legal Information Institute, Cornell Law School. Accessed September 28, 2026. https://www.law.cornell.edu/cfr/text/42/424.24
3. Code of Federal Regulations. 42 CFR 410.61, Plan of treatment requirements for outpatient rehabilitation services (as amended at 83 FR 60073, Nov. 23, 2018). Legal Information Institute, Cornell Law School. Accessed September 28, 2026. https://www.law.cornell.edu/cfr/text/42/410.61
4. Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs; CY 2025 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Prescription Drug Inflation Rebate Program; and Medicare Overpayments (final rule). Federal Register. 89 FR 97710 to 99057, December 9, 2024; effective January 1, 2025. Document 2024-25382. Section on certification of therapy plans of care with a physician or NPP order, 89 FR 97912 to 97918. Accessed September 28, 2026. https://www.federalregister.gov/documents/2024/12/09/2024-25382/medicare-and-medicaid-programs-cy-2025-payment-policies-under-the-physician-fee-schedule-and-other
5. Noridian Healthcare Solutions. Outpatient Therapy Certification Plan of Care, JF Part B. Last updated September 8, 2025. Accessed September 28, 2026. https://med.noridianmedicare.com/web/jfb/specialties/outpatient-therapy/outpatient-therapy-certification-plan-of-care

Written and checked by the PocketPhysio editorial team. Last updated 2026-09-28.