You’ve heard the adage that fact can be stranger than fiction, right? Well, when it comes to Medicare rules, both fact and fiction can seem pretty strange—at least at first glance. But rehab therapists who work with Medicare patients need to know the rules if they want to remain compliant and get paid.
So, to help you navigate Medicare’s evolving regulatory landscape, we’ve compiled the most common Medicare Part B myths that trip up PTs, OTs, and SLPs.
(Disclaimer: If you’re ever in doubt as to how to handle a real-life Medicare scenario, be sure to consult a compliance expert or your local Medicare Administrative Contractor (MAC).)
Myth 1: Providers should issue ABNs to all Medicare patients at the onset of care.
The facts: An Advance Beneficiary Notice (ABN)—a.k.a. a waiver of liability—is a notice therapists use when they believe that, based on coverage rules, Medicare will not pay for the service. Sounds like a good backup plan, right? Here’s the catch: Medicare strictly prohibits providers from using ABNs on a regular, routine basis.
Instead, you should only have patients sign ABNs when you are providing services you know are not covered by Medicare or not medically necessary.
Myth 2: Definitions of CPT terms only apply to Medicare.
The facts: You know the buzzwords: “requires direct one-on-one contact,” “group therapy,” and “supervised modalities.” But, did you know that it’s actually the American Medical Association who developed, copyrighted, and owns all CPT codes and corresponding definitions? This means that all HIPAA-covered entities—that is, all licensed healthcare providers and health insurance companies—must adhere to these standards.
Myth 3: When a therapy cap is reached, the therapist should always stop providing treatment until after the cap resets.
The facts: Has your patient’s Medicare coverage reached its therapy cap? Ready to call it quits? Not so fast! You actually have two options:
- If therapy beyond the cap is medically necessary, you, as the therapist, should continue treating the patient and billing Medicare—with the KX modifier affixed to the claim.
- If you determine that treatment above the cap is not medically necessary, but the patient wishes to continue receiving therapy anyway, you can continue to treat the patient on a self-pay basis by issuing an Advanced Beneficiary Notice (ABN).
To learn more about the ins and outs of the therapy cap, check out this resource.
Myth 4: Before seeing a Medicare beneficiary, rehab therapists must obtain a physician referral.
The facts: This is just another oft-repeated Medicare myth. Rehab therapy providers may perform an evaluation for a Medicare beneficiary without receiving a physician referral. That said, Medicare will not pay for outpatient rehab therapy services without a physician or non-physician provider-certified plan of care.
Myth 5: CMS doesn’t allow students to treat Medicare patients.
The facts: Medicare does allow students to treat Medicare Part B patients—as long as certain stipulations are met, such as the licensed therapist or therapist assistant:
- Is present in the room for the entire treatment session;
- Directs the service;
- Makes skilled judgment calls; and
- Takes responsibility for all assessment and treatment decisions.
Myth 6: Therapists can never accept cash from Medicare beneficiaries.
The facts: This is just a plain old lie. Therapists can accept cash from Medicare beneficiaries for services that are either never covered by Medicare (e.g., wellness services) or, if an ABN is in place, when usually covered services are not medically necessary.
Myth 7: Medicare will stop paying for rehab therapy if a patient doesn’t show improvement as a result of that care.
The facts: Medicare coverage for outpatient physical, occupational, and speech therapy services does not depend on a patient’s potential for improvement from the therapy. Coverage is actually based on the beneficiary’s need for skilled care.
Myth 8: You can never double-book Medicare patients.
The facts: Medicare has no rules or regulations as to how therapists schedule their Medicare patients. CMS does require, however, that therapists bill the correct number of time-based units for the amount of time spent one-on-one with that patient.
Myth 9: Providers need to perform a reevaluation on Medicare beneficiaries every ten visits.
The facts: This one is just another piece of Medicare folklore. Medicare does not require providers to perform reevaluations on patients; rather, reevaluations should only be performed under very specific conditions (e.g., if a patient is not responding to the current plan of care or new clinical findings arise). Medicare does require providers to complete a progress note every ten visits—at minimum.
Myth 10: You cannot bill two CPT codes during the same 15-minute period.
The facts: Medicare allows providers to bill for one or more supervised modalities and any other CPT code—timed or untimed—that requires direct one-on-one contact with the patient. For example, during the same 15-minute period, you can perform—and bill—one supervised modality CPT code (such as 97010: applying hot/cold packs) and a 15-minute time-based CPT code (such as 97110: therapeutic exercise). You could also perform—and bill—for two or more supervised modalities during the same 15-minute period.
Interested in diving deeper into the facts of Medicare coverage requirements? We’ve got you covered (pun intended). Check out this FAQ, this webinar, and this guide.
