During this month’s webinar, compliance experts Heidi Jannenga, PT, DPT, ATC, WebPT Co-Founder and Chief Clinical Officer, and Veda Collmer, JD, OTR, WebPT’s Chief Compliance Officer, discussed strategies for contending with compliance chaos and Medicare mayhem. As they ventured forth into the Medicare labyrinth, they received many queries from fellow adventurers—er, rehab therapists—about the potential pitfalls one might experience while facing the Medicare behemoth. They received so many, in fact, that they simply could not answer them all during the hour-long presentation. So, as promised, we’ve compiled all of the most frequently asked questions and answered them below. Use our handy link bank to jump to any topics of interest. (And if you don’t see an answer to your question, click here to check out our massive library of posts on Medicare compliance.)
Advance Beneficiary Notices of Noncoverage (ABNs)
What is an ABN—and where can I get one?
Advance Beneficiary Notices of Noncoverage (ABNs) are forms that providers use to notify Medicare patients that the services they’re about to receive might not be covered. You can download an ABN form directly from CMS’s website.
Can we issue ABNs for everyone at the beginning of treatment?
Absolutely not. Blanket ABNs are a big Medicare no-no, and CMS has explicitly prohibited providers from doing this.
Does an ABN need to be submitted at every date of service that may not be covered or just once during that series?
No. You only need to have the patient sign an ABN once for the duration of the treatment plan.
How do I know when to issue an ABN?
Start by downloading this free ABN decision chart, which we created to help rehab therapists determine whether it’s appropriate to issue an ABN in any given scenario. Next, take a gander at this excerpt from our recent billing FAQ: “As we explain here, ‘you should only have a patient sign an ABN when you’re providing services that you know are:
- not covered by Medicare, or
- not medically necessary.’
“Here are several specific situations when it is not appropriate to issue an ABN:
- After receiving a denial from Medicare (you can never issue an ABN ‘after the fact’; it must be provided before the service is delivered);
- Anytime a patient exceeds the KX modifier threshold or targeted medical review threshold (if continued treatment is medically necessary, you should apply the KX modifier and continue to bill Medicare; you should only issue an ABN if continued treatment is not medically necessary);
- When you would prefer to collect cash for covered services rather than bill Medicare (even if the patient is willing to pay cash, you cannot accept it; you must bill Medicare for all covered services);
- When providing maintenance therapy (Medicare covers maintenance therapy and does not require patient improvement as a condition of payment);
- In any routine capacity (Medicare strictly forbids providers from issuing ‘blanket’ ABNs to guarantee payment no matter what);
- When you are unable to obtain a signed plan of care within 30 days (even if you made a legitimate attempt to obtain a physician signature); and
- When billing Medicare Advantage rather than Original Medicare.”
Once I’ve issued an ABN, how do I proceed from a billing standpoint?
If you’ve issued a required ABN (i.e., the purpose of the ABN is to transfer financial responsibility for non-medically necessary covered services), then you’ll still need to submit a claim to Medicare. As we explain here, “If you have an ABN on file, you should include a GA or GX modifier on your claim so Medicare knows to deny the claim and assign financial responsibility to the patient. If you submit a claim to Medicare without acknowledging that you know the services are either not covered or not medically necessary, and Medicare denies the claim, you may not go to the patient for payment.”
So, how do you know which G modifier to use? According to this post, the GA modifier indicates that “a required ABN is on file for a service or item not considered reasonable and medically necessary.” Additionally, this modifier allows the “provider to bill the patient or a secondary insurance if Medicare doesn’t cover services” and ensures “Medicare will automatically assign liability to the beneficiary upon denial.” Additionally, “Medicare will use claim adjustment reason code 50 when denying lines due to the presence of the GA modifier (e.g., ‘These are non-covered services because this is not deemed a ‘medical necessity’ by the payer.’)”
The same post notes that the GX modifier indicates that “a voluntary ABN was issued for non-covered services.” (In other words, even though the patient could pay privately without an ABN because the services in question are never covered by Medicare, the provider issued an ABN anyway as a courtesy.)
The GX modifier also prompts “automatic rejection from Medicare” and can “be combined with modifiers GY and TS (to indicate beneficiary liability) but not EY, GA, GL, GZ, KB, QL, or TQ
- TS = Follow-up service
- EY = No doctor’s order on file
- GL = Medically unnecessary upgrade provided instead of non-upgraded item; no charge and no ABN
- KB = Beneficiary requested upgrade for ABN; more than four modifiers identified on claim
- QL = Patient pronounced dead after ambulance is called
- TQ = Basic life support transport by a volunteer ambulance provider.”
Finally, “Medicare systems will recognize and allow the GX modifier on claims, but will return the claim if the GX modifier is used on any line reporting covered charges.”
Keep in mind that there are also G modifiers that can be used when an ABN is not on file. Specifically, as explained in the previously cited post, the GY modifier indicates a statutorily non-covered service and is used “when an ABN is not on file” but the “patient is inherently liable for charges because it’s a non-covered service.” The GZ modifier indicates “that you expect the service to be denied because it isn’t medically necessary” and is used “when an ABN may be necessary but was not issued” meaning the “patient is not responsible for payment.”
Why would I issue an ABN to provide non-medically necessary care (in other words, therapy care that I know Medicare won’t cover)?
According to Collmer, this practice not only protects your practice because it aligns with Medicare’s rules and regulations, but also clearly notifies your patients about what Medicare will and will not cover (so, what they will be responsible for paying out of pocket if they choose to continue). According to Jannenga, the ABN form requires you to share with patients which line items won’t be covered, so after the eval—when you understand which treatment protocols are appropriate—you can provide the ABN to patients and discuss your plan of care, ensuring they understand what to expect from a financial standpoint, thus enabling them to make an informed decision.
If a Medicare patient comes in post-discharge for wellness or fitness services, do we still need to issue an ABN?
For services that Medicare never covers—such as wellness or fitness services—you don’t need to issue an ABN. However, you could issue a voluntary one as a courtesy to the patient.
Is Medicare the only payer that requires ABNs?
Yes; ABNs are documents that are specific to Medicare. Check with your other payers to determine what their policies are for communicating financial responsibilities for non-covered services.
I treat a lot of chronic pain patients and find it difficult to document medical improvement, so I offer a self-pay program under a wellness plan. Do I need to have the patient sign an ABN? Do I have to still submit claims to Medicare?
If the services you’re providing are truly “wellness” services—that is, they are never covered by Medicare—then there would be no need to issue an ABN in order to provide them to a Medicare patient. That being said, if the services actually constitute skilled therapy, then you absolutely should not provide them under the guise of a wellness program and collect payment directly from the patients. Medicare actually covers medically necessary maintenance therapy—so, your chronic pain patients should not pay out-of-pocket for those services. Thus, you would not issue these patients an ABN—and you would submit the claims to Medicare.
If a Medicare beneficiary who has completed a PT course of care would like to continue to use our gym equipment, can we bill a monthly charge without an ABN on file?
Probably. That would likely fall under a wellness program, which Medicare never covers, so you should be able to charge Medicare beneficiaries out-of-pocket without an ABN on file. However, you may want to discuss this with your practice’s attorney to ensure there are no liability issues with using your equipment outside the scope of PT practice.
How much will patients have to pay if Medicare says that a service is not medically reasonable or necessary and the patient hasn’t signed an ABN? Will it be the full amount or the adjusted amount?
If a patient has not signed an ABN, then you cannot legally bill them for services that Medicare denies. Your practice will have to write off the full cost of the service.
What’s CMS’s definition of medical necessity?
- Be safe and effective;
- Have a duration and frequency that are appropriate based on standard practices for the diagnosis or treatment;
- Meet the medical needs of the patient; and
- Require a therapist’s skill.”
For a little more background on the history of this standard—including the APTA’s take—refer to this blog post.
Now, the key to ensuring payment for services that you believe meet that definition—vague though it may be—is documenting with medical necessity in mind. That’s why we’ve written an entire post explaining how to do just that. Check it out here.
What should I do if I, as the PT, do not believe continued therapy is medically necessary—but the patient’s physician continues prescribing it?
In this scenario, Collmer recommends opening the lines of communication. Get in touch with the physician and explain your stance—preferably backed by data (e.g., outcomes data) showing that the patient does not require additional therapy services. Explain that based on your professional ethical code of conduct, you should not be providing non-medically necessary treatment and billing Medicare for it. You may also want to consider educating the patient on why these services are no longer medically necessary.
How can we effectively document medical necessity once a patient goes beyond the therapy soft cap? Is there certain verbiage we should use?
Best practices for documenting the medical necessity of your treatment remain the same whether or not the patient has exceeded the therapy threshold. So, to use an example, if you are providing therapeutic exercise that is medically necessary—regardless of whether the patient has gone over the soft cap—your documentation should communicate the necessity of your skilled care. For instance, you could explain that this exercise will decrease the patient’s risk of falling or maximize his or her independence and safety with ADLs. Furthermore, you should be sure to document the specific assistance and cues you provided while delivering this service. It’s less about what you did (number of reps, etc.), and more about why you did it and how your clinical skills and expertise supported service delivery.
If a patient and his or her therapist agree to continue therapy that—according to Medicare—would not be considered medically necessary, can the PT bill the patient directly without submitting a claim to Medicare?
No. If you’re providing services that Medicare usually covers, but won’t for this particular patient, then you must have a signed ABN on file and submit claims to Medicare with the GA modifier.
What should we do if a patient reaches the therapy threshold and continued care is not considered medically necessary under Medicare, but he or she has secondary insurance? Do we still submit the claim to Medicare before submitting the claim to the secondary insurance?
In order for the secondary insurance to kick in, you must submit a claim to Medicare first to get a denial. Then—and only then—you should submit the claim to the secondary payer. However, bear in mind that if Medicare doesn’t deem the services medically necessary, there’s a good chance that the secondary insurance will not cover them, either. This is because many private payers have adopted Medicare’s definition of medical necessity. So, once the patient reaches his or her goals, you’re typically better off issuing an ABN if the patient wishes to continue treatment. That way, the patient understands that he or she will be financially responsible for continued therapy—and you’ll be covered.
Can Medicare beneficiaries legally choose to pay cash to any PT provider and not use their Medicare benefits if they don’t want to? What are the risks to the PT in that scenario?
We’ve discussed the various relationships a PT can have with Medicare (and how that impacts a PT’s ability to accept cash payments) in several posts on the WebPT Blog:
- 4 Things to Know About Billing for Cash-Pay PTy
- 5 Medicare Compliance Issues for Cash-Based PTs
- Medicare and Cash-Pay PT Services, Part 1: The Must-Know Concepts to Avoid Legal Issues and Capitalize on Opportunities
- Medicare and Cash-Pay PT Services, Part 2: Covered vs. Non-Covered Services and Therapy Cap Essentials
- Medicare and Cash-Pay PT Services, Part 3: Maintenance Care and Self-Payment
On the whole, physical therapists cannot accept cash payments from Medicare beneficiaries for covered services unless the therapist is a non-participating provider. But as Meredith Castin, PT, DPT, Founder of The Non-Clinical PT, explains here, even then, non-participating providers “can accept cash payment from Medicare patients at the time of treatment, but you must submit claims to Medicare so that Medicare can reimburse the patient.”
Are there any loopholes that would allow a PT to accept cash payments from Medicare beneficiaries?
There are a lot of differing opinions on this. Some providers feel that language in a 2013 HIPAA update allows for Medicare beneficiaries to forbid their PT from submitting their claims to Medicare and instead pay the PT directly. Specifically, the rule in question states: “With respect to Medicare, it is our understanding that when a physician or supplier furnishes a service that is covered by Medicare, then it is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act (the Act), which requires that if a physician or supplier charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the physician or supplier must submit a claim to Medicare. However, there is an exception to this rule where a beneficiary (or the beneficiary’s legal representative) refuses, of his/her own free will, to authorize the submission of a bill to Medicare. In such cases, a Medicare provider is not required to submit a claim to Medicare for the covered service and may accept an out of pocket payment for the service from the beneficiary.”
This article from cash-based PT Dr. Jarod Carter covers this “loophole” more in depth. In Dr. Carter’s opinion, “physical therapists could be putting themselves at risk if their standard policy with Medicare beneficiaries is to present them all with paperwork stating that they refuse to allow the physical therapist to submit claims to Medicare,” which is an opinion we share.
As a PT who is credentialed with Medicare, can I see a patient privately (either in my home or the patient’s) and get paid cash?
Nope. If you are enrolled as a participating provider, then you have to play by Medicare’s rules. In this scenario, if you provide a Medicare patient with a service that’s medically necessary, you must bill Medicare. If the service is not medically necessary or not covered by Medicare, then you need to have the patient sign an ABN—and then can you collect cash. That said, you can always review your Medicare contract with an attorney to learn more.
What if a patient does not disclose that they have Medicare and they wish to pay cash? If we collect cash, can we be held liable since we didn’t know the patient was covered by Medicare?
Technically, yes. If you’ve found yourself in this situation, we’d suggest reaching out to an attorney who specializes in Medicare for advice.
Can a patient pay cash for supplies not covered by Medicare?
Yes, a patient can pay cash for supplies that are not covered by Medicare, and in most cases, an ABN would not be required—although many practices issue voluntary ABNs as a courtesy to ensure the patient is aware of any potential expenses he or she may incur in order to optimally perform his or her home exercise program. (To learn more about voluntary ABNs, check out the section of this post titled, “What is the difference between a required ABN and a voluntary ABN?”)
“Medicare and most other insurers do not reimburse for exercise equipment used by the patient at home,” this resource states. “The products used to deliver the service in the clinic, such as elastic bands, are considered ‘bundled’ in the fee for service and cannot be billed separately. However, patients using these products for home exercise programs under the supervision of a healthcare professional may be billed for the cost of the items. In the unlikely event that an insurer reimburses for these products, check with the payor for specific coding requirements.”
I am a sole practitioner, and I’m out of network with all providers (i.e., I only accept cash payment). What do I need to do with regard to seeing Medicare/Medicaid patients to ensure compliance?
As we explain here, if you want to provide Medicare-covered services to Medicare beneficiaries, you’ll need to at least enroll as a non-participating provider and submit claims to Medicare—even if you collect cash from the patient upfront. As for Medicaid, because these programs are run at the state level, there are no all-encompassing rules. I’d recommend reaching out to your state program or your state’s APTA chapter for additional clarification.
If you discharge a Medicare patient, can you legally continue treating the patient on a private pay basis at a discounted rate?
No. Offering patient discounts is tricky legal business to begin with—and offering Medicare patients discounted rates will probably land you in some hot water with CMS (unless the patient is experiencing financial hardship). The only scenario where a Medicare patient can pay out-of-pocket is if the service is:
- not medically necessary (and an ABN is on file), or
- not covered by Medicare.
Therapy Threshold and KX Modifier
What is the therapy cap?
As we explain here, “CMS officially repealed the hard cap on therapy services and replaced it with a threshold amount (often called the ‘soft cap’) beyond which therapists must apply the KX modifier in order to receive payment for medically necessary services. (So, although the repeal was a hard-won victory on the advocacy front, for all intents and purposes, therapists’ claims workflow hasn’t really changed.)” In 2019, the soft cap is $2,040 for PT and SLP services combined and $2,040 for OT services. To learn more about the therapy threshold (and its history), check out this resource.
Can I apply the KX modifier at the beginning of an episode of care? Is there a penalty or compliance issue with applying the KX early?
Unfortunately, you cannot affix the KX modifier until the patient has exceeded his or her therapy threshold. If you apply the KX modifier before it is necessary, Medicare will reject the claim.
If a patient uses most of his or her Medicare Part B PT benefits somewhere else, and then the patient comes to your clinic and you end up going over the $3,000 limit, will your practice be subject to the medical review process?
Regardless of how the patient arrived at the threshold, if you are actively providing care beyond it, then the potential medical review implications will affect your practice. That being said, assuming that the patient has already exceeded the initial therapy threshold (i.e., the “soft” cap), you should already be thoroughly documenting the medical necessity of your treatment. And as long as you’re providing medically necessary services and your documentation supports the continuation of care beyond the threshold, then the review isn’t anything to be concerned about.
What happens if a patient goes beyond the $3,000 manual medical review threshold?
If a patient surpasses the $3,000 manual medical review threshold, nothing happens—at least not immediately. As we mention in this blog post, “CMS will not subject claims over the $3,000 threshold to the targeted medical review process unless the provider falls into a small percentage of therapists who meet certain criteria (e.g., the provider has a high claims denial rate or demonstrates aberrant billing practices compared to peers).”
Do KX modifiers need to be submitted for each claim beyond the soft cap, or just once?
You’ll affix the KX modifier to all claims that exceed the annual threshold.
Does the KX modifier apply to hospital-based outpatient programs?
Yes, assuming the treatment is carried out under a Part B plan of care.
If you submit a claim without a KX modifier, but then you realize you should have used it, can you resubmit with KX added on?
Yes; per this ASHA resource, you can resubmit your claim with the correct modifier if you’ve accidentally left it off. Just be sure your documentation clearly supports the medical necessity of continued services.
Do the therapy threshold and KX modifier apply to Medicare Advantage?
Medicare’s Part B therapy threshold does not apply to Medicare Advantage plans (for a complete list of services that count toward the therapy threshold, refer to this resource). But, as the APTA explains here, a Medicare Advantage plan may choose to apply a cap to its services “with an exceptions process if it so chooses to do so. However, many Medicare Advantage plans have chosen not to apply a therapy cap in the past. You should check with your Medicare Advantage plan regarding its payment policies.”
Progress Notes and POCs
What are Medicare’s guidelines regarding progress notes and signed plans of care (POCs)?
As we explain here, “At minimum, a licensed therapist must complete a progress note for every patient by his or her tenth visit. In it, the therapist must:
- Include an evaluation of the patient’s progress toward current goals.
- Make a professional judgment about continued care.
- Modify goals and/or treatment, if necessary.
- Terminate services, if necessary (see the discharge note section below).”
Regarding POCs, “Medicare requires that a licensed physician or nonphysician practitioner (NPP) date and sign the POC within 30 days.” That means patients may self-refer to receive therapy services—and therapists may begin treatment prior to obtaining a physician signature. However, we recommend only proceeding with treatment if you are confident that you can obtain the physician signature within that time frame. While Medicare does not require that patients complete an appointment with a physician prior to receiving that POC signature, some physicians do want to see the patient first.
As a side note, this is why we recommend building relationships with PT-friendly physicians in your area. That way, if you need a POC certification in a pinch, you’ll always have someone to call. For more info on the benefits of finding a physician bestie, check out this blog post.
If a patient switches to Medicare primary mid-treatment, do we need to do another initial evaluation and follow the Medicare plan of care certification process?
Yes. If the patient switches to Medicare from another payer (commercial, for example), you must follow Medicare’s plan of care certification process. That means you must complete a new initial evaluation, ship the POC to the physician to obtain his or her signature, and follow all of Medicare’s documentation and plan of care rules. If you use WebPT, Jannenga suggests using the Quick Discharge function so the previous POC is complete—and then documenting in the chart that you previously provided care. (As she explained, the therapist can complete a quick discharge whenever a patient suddenly stops treatment before the anticipated discharge date.)
If a patient hasn’t been in for treatment in over 30 days, but he or she returns to therapy before his or her tenth visit, does the therapist need to complete a progress note immediately upon the patient’s return?
No. Historically, Medicare required PTs to complete a progress note either every tenth visit or 30 days—whichever occurred first. However, Medicare removed the 30-day requirement back in 2013, which means a progress note is only required on the tenth visit.
What should we do if we can’t obtain signed POC in 30 days?
Continue trying—and be sure your documentation clearly explains the reasons behind the delay. Furthermore, every time you make an attempt to obtain a signature, document the method (e.g., in person, fax, sent with the patient, etc.) as well as the date and time. At its discretion, Medicare may decide to reimburse for services because you’ve made a concerted effort to get the signature. As Jannenga mentioned during the webinar, when she was in practice, she would sometimes accompany her patient to his or her follow-up appointment with the physician in order to get a signature right then and there. If that’s not possible, get the patient involved by sharing that you need a signature in order to continue treatment.
Does the certifying physician have to be the patient’s regular physician?
No. Medicare does not require that the physician who signs the POC be the physician who referred the patient for treatment. However, there is a professional courtesy to consider when interacting with referring physicians.
In the past, we have had patients refer themselves and give us an MD’s name, but the MD refuses to sign off on the POC because he or she has not seen the patient in months. What’s the solution here, other than requiring a referral at all times?
In that case, we would recommend obtaining the physician signature after the initial evaluation—but before beginning treatment. That way, you can share with the patient that he or she needs to have an appointment with his or her physician before beginning therapy—and you won’t be left writing off services because you can’t obtain a physician signature. This is also a good time to note that Medicare does not require that the physician who signs the POC to be the patient’s primary physician, which is another reason to develop a network of PT-friendly physicians you can refer patients to.
Does the initial evaluation count toward the ten-visit deadline to complete a progress note?
Yes. The initial evaluation counts as visit number one, which means the progress note is required on the patient’s tenth visit to your clinic. The visit count then resets, starting with the 11th visit as visit number one of the next series.
When a current patient comes in with a new diagnosis, should I do a reevaluation and add the diagnosis to the current case, or complete another initial evaluation and start a new case?
According to this blog post, if a current patient develops a new and unrelated condition, you should administer an initial evaluation and open a new case. However, if the new condition is related to the diagnosis you’re already treating, then you would administer a reevaluation and update your plan of care.
Do I still need to have the physician sign the POC if he or she has already signed the script?
Yes. The script (a.k.a. prescription) does not serve as a signed POC; it simply means that the prescribing physician agrees that the patient needs therapy. After your evaluation, you’ll send the POC to the physician for a signature. Now, if the physician sent you a script that says “evaluate and treat three times a week for six weeks”—and through your evaluation, you recognize that the patient won’t need that much treatment—then you’d scale back the POC. And that’s what the physician would sign-off on: the revised treatment plan. For more information on Medicare’s POC signature requirements, refer to this blog post.
Can we bill for a re-eval when we complete a progress note or discharge a patient?
You should not automatically bill for a re-evaluation whenever you complete a progress note or discharge note. Your ability to bill really depends on whether your services—and your documentation—meet the criteria for when a re-eval is warranted. To that end, for a re-eval to be appropriate, the patient must have experienced a significant change that impacts his or her plan of care. A routine progress assessment and discussion of the therapy exercise program, HEP, or treatment plan doesn’t warrant a re-eval—nor does an assessment to determine whether a patient has met his or her goals and is ready for discharge. However, if the patient comes in with a significantly different symptom or problem—after suffering an unexpected fall, for example—then it would be appropriate to perform, document, and bill for a re-eval and change the treatment goals and plan accordingly. To learn more about when it is—and isn’t—appropriate to bill for evaluations and re-evaluations, check out this blog post.
Can any PT who is onsite supervise a PTA—or does it have to be the PT who performed the initial evaluation?
According to Collmer, the supervising PT doesn’t necessarily have to be the therapist who performed the initial evaluation; however, you will be billing the visit under that supervising PT’s NPI, so he or she must be credentialed with Medicare as well as available and familiar enough with the patient’s care to be able to intervene if necessary.
Can a PTA or OTA complete a progress note?
Medicare allows PTAs to sign off on daily treatment notes. However, evaluations, progress notes, and discharge summaries cannot include a PTA’s signature. Additionally, if a PTA and PT collaborate on a document, the PT or PTA should include language that indicates this within the documentation.
How do supervision requirements work for PTAs who furnish outpatient home health treatment? Is it not possible to use a PTA, because a PT would not be onsite?
According to Rick Gawenda, the Medicare Part B program requires PTAs to practice under direct supervision (i.e., the supervising therapist must be physically onsite) in private practice settings. This includes private practices providing outpatient therapy in a patient’s home. In non-private practice settings, Medicare only requires general supervision (i.e., the supervising therapist must provide initial direction and period course-correction, but he or she does not have to be onsite).
How many visits can a PTA see the patient before the PT must get involved again?
A PTA can see the patient for every visit excluding evals and progress updates. This means the most consecutive visits a PTA can see a patient is nine (9) visits, at which point a progress note would be required.
If a PTA treats a patient, should we bill under the PTA’s NPI or the PT’s?
For Medicare, you’ll bill under the PT’s NPI. During the webinar, Jannenga added that most PTAs don’t have an NPI. However, you must indicate on the HCFA form that a PTA performed the services. Also, starting next year, you must affix a modifier to every service delivered in whole or in part by a PTA or COTA (i.e., the assistant delivered more than 10% of the service).
Can you explain how billing “incident to” affects the new PTA and OTA modifiers?
According to the 2020 proposed rule, “the CQ and CO modifiers would not apply to claims for outpatient therapy services that are furnished by, or incident to the services of, physicians or nonphysician practitioners (NPPs) including nurse practitioners, physician assistants, and clinical nurse specialists.” In other words, if a PT or OT is billing incident-to a physician or NPP, then the CQ and CO modifiers will not be required on the claim—even if a PTA or OTA furnished more than 10% of the service.
In an outpatient clinic with only one PT, how can PTAs see Medicare patients when the PT is out sick or on vacation?
Medicare will not reimburse for services provided by a PTA unless a licensed PT is available to provide direct supervision. Thus, in order to bill for PTA-provided services when the primary PT is out of the office (and thus not able to intervene if necessary), you’d need to hire a temp PT who is credentialed with Medicare. For detailed guidance on billing for temporary therapists, check out this blog post.
Can PTAs or therapy students ever treat Medicare beneficiaries?
PTA-provided services are reimbursable if Medicare’s supervision requirements are met. Students can treat Medicare patients, but their services aren’t usually reimbursable. As we explain here, “Medicare Part B will not provide payment for services that a therapy student provides, because therapy students aren’t licensed providers. So, even if the therapist is in the room with the student while the student provides the services, only the services of the licensed therapist are billable. Now, there are some exceptions to that rule, including the following:
- ‘The qualified practitioner is recognized by the Medicare Part B beneficiary as the responsible professional within any session when services are delivered.
- ‘The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
- ‘The qualified practitioner is present in the room guiding the student in service delivery when the student is participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.
- ‘The qualified practitioner is responsible for the services and as such, signs all documentation.’”
As a note, beginning in 2020, providers are required to include a payment modifier (CQ for PTAs and CO for OTAs) in addition to therapy modifiers on claims when a therapy assignment provided at least 10% of a service. Beginning in 2020, Medicare will reduce reimbursements for assistant-provided services to 85%.
Will PTAs have to use a specific modifier on claims in 2020? What’s the modifier?
Yes. Beginning in 2020, when a PTA or OTA provides more than 10% of a service that’s being billed to Medicare Part B, the claim line must include an assistant modifier: CQ for PTAs and CO for OTAs. This modifier will then trigger a 15% reimbursement reduction. Check out this blog post for more information.
Will I need to apply the new PTA and OTA modifiers per CPT code or per treatment?
You will need to apply a therapy assistant modifier on each individual service line (i.e., each CPT code) that the assistant furnished “in whole or in part.”
We are a critical access hospital (CAH) and are exempt from the upcoming therapy assistant reimbursement reduction. Will we still need to apply the CQ and CO modifiers when we bill Medicare?
Unfortunately, the legislation does not specify whether or not CAHs will have to use the CQ and CO modifiers. It only (very specifically) states that “the reduced payment rate…is not applicable to outpatient therapy services furnished by CAHs.” We hope that CMS will provide more concrete guidance in the 2020 final rule!
Under Medicare guidelines, can outpatient physical therapists bill under a physician’s order to give therapy inside a patient’s home? If so, how?
According to CGS Medicare, you can furnish outpatient care to a patient in his or her home and bill Medicare Part B if the patients “are not homebound or otherwise are not receiving services under a home health plan of care (POC).” Keep in mind that if the patient is homebound or currently under an inpatient POC, the claim will automatically be denied.
How do you verify if a patient is receiving home health services?
The best way is to ask the patient—making your question as clear as possible to ensure the patient considers all forms of at-home health services. As we explain here, “if the patient was previously receiving home health care, verify that the patient has been discharged. In these types of settings, there’s often a nurse who comes in for routine services, like checking a patient’s blood pressure. In that case, the patient is receiving home health services; thus, you won’t receive payment for providing Part B services.”
Shouldn’t a patient have some liability when failing to inform us about receiving concurrent home health care? Is there anything we can do to recoup payment?
Unfortunately, there isn’t a whole lot you can do other than trying to appeal to Medicare, but there’s no guarantee that CMS will reply favorably. The best practice to determine if your patients are receiving concurrent care under Medicare Part A is to ask your patients if they are receiving care from any other provider—and what the details of that care are.
If a clinic does not have an EMR, how can it report MIPS in order to remain compliant with Medicare?
Small clinics (i.e., clinics with a TIN that encompasses 15 or fewer MIPS-eligible clinicians) have the option to participate in claims-based reporting. That process involves sending in claims to Medicare as normal—but manually adding QDC codes to those claims to fulfill reporting requirements for certain measures. However, CMS is working to phase out all claims-based reporting, and it’s really pushing providers to report via QCDR. So, if you’re interested in participating in MIPS, there’s never been a better time to go digital!
If we didn’t see enough Medicare patients last year to qualify for MIPS, will that affect our payments in the upcoming years? If we decide to start participating in MIPS, how do we report—and what exactly do we need to report on?
If you didn’t meet the requirements to participate in MIPS in 2019, no need to fret! Your Medicare reimbursements will be unaffected in 2020 and 2021. However, it’s possible that you might be required to participate in 2020. If that’s the case, you’ll need to jump through a handful of reporting hoops next year to sidestep a penalty to your Medicare reimbursements. MIPS reporting can get pretty complicated, so we recommend checking out this page to learn more about how therapists can participate in the program.
How do we justify seeing long-term chronic pain patients if they are not making much progress with regards to their condition? Do they get the same exceptions as patients with neurodegenerative diseases such as multiple sclerosis (MS) or Parkinson’s?
As long as the services meet Medicare’s definition of medical necessity, you can continue providing maintenance therapy to patients. To that end, Medicare reimbursement for outpatient physical therapy services is not contingent on improvement. As we mention in this WebPT Blog post, “Medicare statutes and regulations have never supported an improvement standard as a requirement for reimbursement. Coverage is not dependent on the beneficiary’s restoration potential, but rather, whether or not skilled care is necessary to meet the medical needs of the patient.”
Where can I read more information about the Jimmo settlement?
You can read more about the Jimmo settlement here and what that means for maintenance therapy here.
Can a PTA provide maintenance therapy?
No; according to the APTA, PTAs cannot provide maintenance therapy under Medicare Part B.
What are the documentation requirements for maintenance therapy—and is there anything we need to watch for to prevent denials?
Ultimately, your documentation should support the medical necessity of your services as well as the patient’s need for your skilled care. As Collmer explained during the webinar, Medicare is looking for your services to:
- “Be safe and effective;
- “Have a duration and frequency that are appropriate based on standard practices for the diagnosis or treatment;
- “Meet the medical needs of the patient; and
- Require a therapist’s skill.”
Thus, you’ll want to be sure that your documentation addresses each. To learn more about billing for medical necessity, check out this blog post. To learn more about defensible documentation best practices, download this free toolkit.
If a patient has MediCal (the California version of Medicaid) and we don’t accept that, can the patient choose to pay for therapy out of pocket?
Because Medicaid is a state-run program, each state has its own rules and regulations. For that reason, you’ll want to reach out to MediCal directly. Here’s the page that contains the program’s contact info.
Do Medicare Supplement and Medicare Advantage Plans adhere to the same rules as Medicare Part B?
As we explain here, “Medicare and Medicare Advantage (MA) plans have similar structures, because MA plans are required to (at minimum):
- offer the same benefits that traditional Medicare provides to its beneficiaries, and
- adhere to all CMS National and Local Coverage Determinations.
However, there are some significant differences between the two. And that makes sense given that traditional Medicare is government-operated, while Medicare Advantage plans are operated by Medicare-approved private companies. Thus, many of the core Medicare requirements don’t automatically apply to Medicare Advantage plans.”
Additionally, as we write here, “Medicare Supplement Insurance—a.k.a. Medigap—is a private insurance policy that helps pay for some healthcare costs that Original Medicare doesn’t, including deductibles, copays, coinsurances, and, in some cases, healthcare expenses incurred outside of the US.” Because providers should bill Medicare first for patients with Medicare supplement policies, it’s important to adhere to all Medicare rules and regulations—regardless of which plan ends up paying.
Our regional Medicare contractor is National Government Services. Their guidelines state that a patient may self-refer to PT. However, a physician must sign off on the POCs. Isn’t that contradictory?
It may seem contradictory, but it’s correct. After all, even in cases involving physician referrals, a referral does not equate to a POC certification. While Medicare patients may self-refer to therapy services under direct access, therapists are required to obtain a physician signature on the plan of care within 30 days.
Will dry needling be a covered service in 2020?
- 205X1: “Needle insertion(s) without injection(s), 1 or 2 muscle(s); and
- 205X2: “Needle insertion(s) without injection(s), 3 or more muscle(s).”
CMS is also considering classifying these codes as “always therapy” procedures (i.e., they could only be furnished by a PT, OT, or SLP). We’ll publish a blog post with more information after the release of the final rule in November. Keep your eyes peeled!
How should we handle providing—and billing—for dry needling under Medicare?
This blog post provides a rundown of everything you need to know about billing for dry needling. To find out whether Medicare covers dry needling in your region, consult with your Medicare contractor. Additionally, note that CMS has floated some big changes to billing for dry needling as part of its 2020 proposed rule. So, stay tuned to see which ones are accepted as part of the final rule.
Can occupational therapists see Medicare patients under the same direct access rules as PTs?
Unfortunately, OTs are subject to different direct access laws than PTs—and those laws are typically more restrictive. If your state allows OTs to see patients without referrals, then yes, OTs can see Medicare patients in the same way that PTs can (i.e., a certified POC is required within 30 days of the first treatment). But, don’t forget that you have to adhere to the strictest compliance rules that apply to you—so if your state says direct access is a no-go, then you’re out of luck.
Can PTs who practice in unrestricted direct access states treat Medicare patients without a physician’s order or POC signature?
Medicare does not require providers to obtain a physician referral or order to perform an initial evaluation or begin treatment; however, providers must obtain a physician-signed POC within 30 days—regardless of the level of direct access available in their state.
What should I typically include in my daily documentation?
Thorough and defensible documentation is imperative if you want to stay compliant, prevent denials, and deliver the best possible care to your patients. It should:
- Include information about the patient’s functional status, how care is being managed, and the expected outcome;
- Communicate a provider’s abilities, expertise, and services;
- Demonstrate a provider’s compliance; and
- Demonstrate medical necessity.
For more information and examples, check out our defensible documentation toolkit.
Are there any billing or documentation red flags that can trigger a Medicare audit?
We’ve actually covered this topic on a couple of blog posts, which you can read here:
- 6 Surefire Signs Medicare Will Audit Your PT Practice (and How to Fix ‘Em)
- CMS Audits: Who, What, and Why
Does WebPT track the 30-day window for obtaining POC signature?
Yes! WebPT users can track the status of a signed plan of care using the Plan of Care report in the app. For more information on using this tracking feature, check out this article from the WebPT Community.
How do I deactivate the functional limitation reporting requirement in the WebPT app?
In 2019, WebPT made functional limitation reporting in the EMR totally optional—however, Members had to manually opt out of the FLR requirements. For instructions that explain how to opt out of FLR requirements, take a look at this article from the knowledge base.
How will the WebPT EMR handle the PTA and OTA modifiers in 2020? Will WebPT create a space on claims to note that a PTA was or was not involved with care? Will the modifiers automatically populate on claims?
Users of the current version of our SOAP notes will be able to use the additional modifier functionality by selecting a preference in Company Settings. We’re also adding functionality to ensure compliance with this requirement to our next-generation SOAP 2.0 system. We will have more information on that system update available later this year, so keep your eyes peeled!
Has FLR officially ended?
FLR has officially ended for Medicare; however, some third-party payers may still require functional limitation reporting. So, your best move is to check in with your third-party payers.
How do we handle a Medicare patient who cancels his or her discharge appointment?
If you’re a WebPT user, then you can use the Quick Discharge functionality based on the information garnered during that patient’s prior appointment.
Does Medicare prohibit providers from having two different fee schedules for different insurance providers?
No—Medicare does not prohibit providers from having different fee schedules for different payers. You’re free to set different fee schedules in order to help ensure your practice’s financial viability. And, according to the APTA, Medicare “no longer demands a provider’s lowest fee.”
As telehealth becomes more common, are the rules regarding PTA supervision posed to change? For example, if the supervising therapist is available via telehealth, can a PTA see a Medicare patient in an outpatient setting?
Medicare has not released any official guidance on the use of telehealth as it relates to supervision. However, as WebPT’s Erica McDermott explains here, PTAs must be under the direct supervision of a PT, which generally means the PT is on the premises (but not necessarily in the same room) so he or she can intervene if need be. So, until Medicare clarifies its rules regarding telehealth’s use for supervision, we recommend continuing to only allow PTAs to treat patients with the supervising PT physically on site.
We have an acupuncturist in our therapy practice. Medicare does not cover acupuncture, so should we be adding using the GY or GX modifiers?
For services that are never covered by Medicare, you could issue a voluntary ABN and affix the GX modifier, triggering Medicare to deny the claim. However, Medicare does not require that you do so. You can collect from the patient directly either way.
Can you bill for multiple body parts in a single visit?
Yes! However, you may need to affix the 59 modifier to any bundled codes to indicate that the procedures were performed on separate and distinct body parts. Learn more here.
Can we schedule a Medicare patient with a commercially insured patient as long as the PTAs don’t work with the Medicare patient?
As we explain here, “CMS permits providers to treat multiple patients at once, regardless of insurance type.” However, you still must follow each payer’s rules for treatment delivery and billing—and this becomes especially important when PTAs and techs are involved, as Medicare’s rules around extender use are typically more strict than other payers’. The same resource goes on to note, “Regardless of the situation, though, the main thing to keep in mind is that the definition of ‘one-on-one’ services (and the CPT codes for services that are considered one-on-one) is not specific to the payer. These definitions come from the American Medical Association (AMA), meaning they remain the same regardless of insurance. So, the manner in which you calculate one-on-one time shouldn’t differ for patients with different insurances.”
Can we collect coinsurance and deductible payments from Medicare beneficiaries at the time of service?
Yes, you may collect copays and deductibles from Medicare patients at the time of service. In fact, we recommend doing so.
Can we provide outpatient physical therapy to a patient who’s receiving speech therapy in a skilled nursing facility (SNF) setting?
No. You cannot bill outpatient therapy services for any patient who is currently receiving inpatient treatment, and patients who are in an SNF are, by definition, receiving inpatient care.
Can a PT bill for massage if he or she can demonstrate that it is improving function?
No. According to this page from Medicare, “Medicare doesn’t cover massage therapy”—full stop. However, because it’s not a covered service, you can provide it on a cash-pay basis—with or without the use of a voluntary ABN.
Can we bill Medicare for cancellations or no-shows?
No. However, Medicare does allow providers to charge patients fees for missed appointments as long as the following conditions are met:
- “Has a written policy on missed appointments that is provided to all patients. (Providers may also want to obtain patients’ signatures to acknowledge receipt of this policy as an extra preventive measure).
- “Ensures that the missed appointment policy applies equally to all patients.
- “Establishes that the billing staff is aware that Medicare beneficiaries should be billed directly for missed appointments.
- “Ensures that charges for missed appointments are reflective of a missed business opportunity and not the cost of the service itself.”
If a patient is receiving therapy for one condition but goes to another facility to receive therapy for a different condition, will both clinics get paid?
If the patient is receiving outpatient therapy under two separate plans of care—both of which meet Medicare’s requirements—then both providers should receive payment. However, it’s important to note that all of the patient’s care counts toward the same therapy threshold, which makes tracking the total more complicated. Additionally, as we explain in this webinar FAQ, patients may not receive PT services under Part B benefits if the patient is concurrently receiving Part A services from a home health agency, SNF, or acute care setting.
What does a solid compliance plan consist of?
According to Collmer—who serves as WebPT’s In-House Counsel and Compliance Officer—a solid compliance plan, at a very high level, requires the following:
- A named compliance officer (this could even be someone who wears two different hats);
- Written policies and procedures that address compliance (e.g., instructions that cover how to correctly issue ABNs); and
- A hefty amount of staff compliance training.
Collmer recommends that practices base their training on strong, solid resources—preferably sources that are recent and that pull directly from payer guidelines. To learn more about the how and why of rehab therapy compliance plans, check out this blog post authored by Collmer.
On my treatment note I duplicated all of the activity that I may perform under each modality. Our auditor is saying this information needs to be updated and only include what was actually done. I want to keep my list intact on each visit to remind me of the different exercises I may want to use. The auditor indicated I need a separate list so that it does not appear on the list of what I performed. Is this true?
What the auditor is requesting makes sense, given that your treatment notes should clearly indicate to anyone who is reading them what was actually provided during each date of service. We would recommend adhering to this request.
If we have a new therapist who is not yet credentialed with Medicare, can another therapist cosign and bill on the new therapist’s behalf?
As we explain here, “A therapist can begin treating patients—even if he or she is not yet officially Medicare credentialed—as long as the Medicare credentialing paperwork is pending CMS’s approval. However, the practice must hold all billing claims for that therapist (up to one year from the date of service, per timely filing rules) until the credentialing approval comes through.” Furthermore, “Medicare won’t allow credentialed therapists to cosign claims for non-credentialed employees, so the uncredentialed therapist should reassign his or her individual Provider Transaction Access Number (PTAN) to the practice, and that practice should hold all the claims until he or she is fully credentialed.”
That being said, as Collmer alluded to during the webinar, the rules may be different for different payers. The same resource goes on to note that several “non-Medicare insurance companies allow a credentialed therapist to cosign a non-credentialed therapist’s note if the cosigning therapist supervises the treatment. Similar to the rules governing billing for PTA services, the credentialed therapist must provide direct onsite supervision and be immediately available to intervene if necessary.” However, this should only be used as a temporary solution during the short period of time during which the new therapist is awaiting credentialing—not as a permanent fix.
Medicare won’t pay for the time a patient spends resting between exercises, but can I provide—and bill—for education during that time?
According to Jannenga, that is an excellent way to use patient rest time to provide medically necessary services and skilled care. If you are truly educating the patient on things such as ADLs or breathing techniques—anything that will help them meet the goals you’ve set together—then yes, you may absolutely bill for education during that time. Just be sure to clearly document the education that you provided as well as the impact you believe that education will have on the patient’s progress toward his or her goals. To learn more about what constitutes patient education—and how to bill for it—check out this blog post.
Does exercise on a stationary bike constitute skilled care—and does it meet the billing requirements of CPT 97110? Should there be documentation to indicate the patient is not able to do this independently, and if so, what kind of documentation would be required?
According to this source, exercise on a bike can constitute skilled care if the therapist is consistently adjusting and progressing the program. But, as soon as a patient can independently exercise without “frequent assessment or progression,” then exercise on the stationary bike is no longer considered skilled care and will not be covered by Medicare. To prove that exercise on a stationary bike is skilled, medically necessary care, documenting defensibly is key. Take a look at our Defensible Documentation Toolkit; it will walk you through a handful of example scenarios that are similar to this one.
As ye olde Medicare adventure draws to a close, take heart! You now have all the tools you need to conquer Medicare billing—and to successfully complete your compliance quest. But, if you still feel underequipped and you want to pack another tip or trick into your arsenal, feel free to speak your worries below! (In other words, leave your remaining questions in the comment section, and we’ll do our best to answer them.)