Who May Sign the Certification or Recertification for Extended

40.1 - Who May Sign the Certification or Recertification for Extended Care Services (Rev. 120, Issued: 11-02-18, Effective: 12- 04-18, Implementation: 12- 04-18) A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner, a clinical nurse specialist or, effective with items and services furnished on or after January 1, 2011, a physician assistant) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. See Pub. 100-02, Medicare Benefit Policy Manual at chapter 8, §40.1, for a discussion of “direct” and “indirect” employment relationships in this context, and at chapter 15, §190.C (for physician assistants), §200.D (for nurse practitioners), and §210.D (for clinical nurse specialists), regarding the required collaboration between the physician and the physician extender. Ordinarily, for purposes of certification and recertification, a “physician” must meet the definition contained in Chapter 5, §70 of this manual.