Doctors of medicine (MDs), doctors of osteopathy (DOs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs) can all sign home health orders under current federal Medicare rules. This wasn’t always the case. Until 2020, only physicians could certify a patient for home health services, but a permanent change in federal law expanded that authority to these non-physician practitioners.
How Non-Physician Practitioners Gained Signing Authority
Before March 2020, Medicare restricted home health certification and ordering to physicians only. Section 3708 of the CARES Act changed that by allowing nurse practitioners, clinical nurse specialists, and physician assistants to order home health services, establish and sign the plan of care, and certify or recertify that a patient is eligible for Medicare home health benefits. While this change was introduced during COVID-19, it was made permanent and is now codified in federal regulations at 42 CFR 409.43.
This means NPs, CNSs, and PAs can now do everything a physician does in the home health ordering process: write the initial order, sign the care plan, and recertify the patient for ongoing services. The practitioner must be working in accordance with state law.
The Full List of Who Can Sign
- Doctors of medicine (MDs)
- Doctors of osteopathy (DOs)
- Doctors of podiatric medicine (DPMs), but only for plan of care functions consistent with what they’re authorized to do under state law
- Nurse practitioners (NPs)
- Clinical nurse specialists (CNSs)
- Physician assistants (PAs)
Certified nurse-midwives can perform the required face-to-face encounter (more on that below), but the broader signing and certification authority applies to the practitioners listed above.
Who Cannot Sign Home Health Orders
Physical therapists, occupational therapists, speech-language pathologists, chiropractors, clinical psychologists, clinical social workers, and optometrists cannot sign home health orders or certify a patient for home health services. Even though some of these practitioners can order other Medicare services, home health certification is limited to the specific group listed above. If your care involves one of these providers, a qualified physician or allowed practitioner still needs to sign the home health order.
State Law Still Matters
Federal regulations require that the signing practitioner work “within the scope of his or her state license, certification, or registration.” This means your state’s scope of practice laws can affect whether a particular NP or PA is authorized to sign home health orders in your area. In states with full practice authority for nurse practitioners, there are typically no barriers. In states that require physician supervision or collaboration agreements for NPs or PAs, the practitioner must meet those state requirements before they can sign.
If you’re unsure whether a specific practitioner type can sign in your state, the home health agency coordinating your care will know. Agencies verify this routinely because claims get denied when the signing practitioner lacks proper authority.
The Face-to-Face Encounter Requirement
Before home health services can be certified, someone must see the patient in person. This face-to-face encounter must happen within 90 days before the start of home health care or within 30 days after care begins. If home health is ordered based on a new condition that wasn’t present during a prior visit, the encounter must happen within 30 days after admission.
The face-to-face visit can be performed by the certifying physician or allowed practitioner, or by a nurse practitioner, clinical nurse specialist, certified nurse-midwife, or physician assistant. When performed by an NP or CNS, that practitioner must be collaborating with the physician in accordance with state law. When performed by a PA, they must be under physician supervision as defined by state law. The purpose of this encounter is to confirm that the patient genuinely needs home-based skilled care, and the practitioner must document what they found during the visit.
What the Signing Practitioner Actually Signs
The plan of care is the central document. It lays out the specific home health services the patient will receive, identifies measurable goals and outcomes, and must be individually tailored to the patient. The physician or allowed practitioner signs this plan to authorize care. Medicare requires that this documentation be signed and dated, with enough detail to show when services were ordered.
Attestation statements can be used to verify signatures on most medical documentation, but they cannot be used to backdate a plan of care. If you use a scribe or any AI-based documentation tool, the ordering practitioner must personally sign the entry to authenticate it.
Recertification Every 60 Days
Home health orders don’t last indefinitely. If a patient needs continued home health services beyond the initial 60-day episode, the physician or allowed practitioner must recertify eligibility at least every 60 days. This recertification happens at the same time the plan of care is reviewed and must be signed and dated by the practitioner who reviews it. The same types of practitioners who can sign the initial order (MDs, DOs, NPs, CNSs, PAs) can also handle recertification.
There are two exceptions where recertification isn’t needed on the 60-day cycle: when the patient transfers to a different home health agency by choice, or when the patient is discharged because their goals have been met and there’s no expectation they’ll return to home health care.
Financial Relationship Restrictions
One important limitation applies regardless of practitioner type. A physician or allowed practitioner who has a financial relationship with a home health agency generally cannot certify, recertify, establish a plan of care, or conduct the face-to-face encounter for patients served by that agency. This anti-kickback protection has narrow exceptions, but the default rule is clear: the person signing your home health orders should not have a financial stake in the agency providing your care.