The pandemic demonstrated that there’s not much that can’t be done in the home, and while most of us are glad to venture out once more for many of those activities, we’ve also come to appreciate and want convenience where we can get it. Which brings us to home-based outpatient physical therapy—while it’s not a new service by any stretch, it certainly grew in prominence during the pandemic out of necessity, and has remained a popular choice for some PT patients even post-lockdown.
Home-based outpatient care can also be a useful treatment option for rehab therapists as well. It’s a great way to retain current patients that might otherwise stop treatment if they had to come into the office for every appointment, and an alternative revenue stream to tap into with new patients. But like other outside-the-box options, it comes with some questions—namely, how should PTs bill for these services? That’s why we’re here to break down what you need to know about documenting and billing for home-based outpatient PT services.
What’s the difference between home health and home-based outpatient care?
First, let’s lay out some basics. As outlined in this blog post, home-based outpatient PT is different from home health PT in how they are billed, if not in the services provided. For the purposes of Medicare, home health care requires that the patient be homebound and in need of PT, OT, and/or SLP services as certified by a doctor, and that the patient has a plan of care created by a doctor. Covered home health services are also billed under Medicare Part A.
Conversely, home-based outpatient PT is for those patients that aren’t homebound, but want the convenience of receiving treatment in their home. For Medicare patients, you would bill those outpatient services under Medicare Part B. It’s also important to note that you won’t be able to bill Part B if the patient is concurrently receiving care under Part A—even if that care is for non-therapy services.
How do I document for home-based PT?
If you’re worried about the potential administrative burden of providing home-based care, you’re in luck—documentation should stay the same as it would if you were treating the patient in your clinic. As Rick Gawenda outlines in this FAQ on outpatient therapy in the home, neither Medicare nor most Medicare Advantage (MA) or commercial insurance providers require any changes to your billing practices when providing in-home services—so continue to use the same CPT codes and modifiers that you otherwise would.
On the point of modifiers, it’s worth reiterating the current, temporary changes to direct supervision requirements as it pertains to the CO and CQ modifiers. As we mentioned in our breakdown of the 2023 final rule, the direct supervision requirements were relaxed to permit virtual presence using real-time video or audio technology through the year in which the public health emergency ends. That means that, at least through 2023, PTs and OTs are permitted to provide direct supervision virtually to PTAs and OTAs, even in the home. (As always, your state’s practice act might have more stringent supervision requirements that must be followed, so be sure to reference those as well.)
What can I bill for with home-based PT?
Just as your documentation won’t change significantly for home-based outpatient PT, your billing practices will also remain largely unchanged. For home health agency PTs that are seeing patients on an outpatient basis, you would use a UB-04 form to submit a claim, using claim format type 34X, under your HHA’s NPI. Otherwise, if you're part of a private practice and using the 1500 claims form, you’ll have to mark the place of service code as “12” for “Home.”
Unfortunately, PTs aren’t able to bill for all of their efforts in providing home-based rehab therapy. The additional expenses you’re incurring to travel to patients’ homes are not covered under Medicare, and aren’t separately billable to either Medicare or to the patient directly, even with an ABN.
What about private insurance?
Unfortunately, with so many different payers implementing their own policies, it’s impossible to say with certainty that home-based outpatient PT is for sure covered, or to speak to what is required to provide those services. Broadly, most commercial and MA plans do cover outpatient PT services provided in the home, but as always you want to verify with the insurance company in question before you start providing the service.
As for providers who are out-of network, there’s greater flexibility as to what they can charge—and what they can charge for. Assuming you’re not enrolled with insurance carriers and not working with Medicare and MA, you can charge non-Medicare beneficiaries for travel expenses, or include those expenses in the overall fees for your service.
It can get a bit complicated for MA plans primary because MA enrollees have their out-of-pocket expenses limited. So, if you’re treating a MA patient with out-of-network benefits, you can only charge them what their plan would pay for those services plus what the patient would have to pay for their share of the cost. If the MA plan doesn’t have out-of-network benefits, patients would be responsible for the full cost of services—unless the patient sought out your services because they weren’t covered by their MA plan, in which case the plan may be required to pay for those services if the patient appeals a denial. (Like I said, complicated.)
So there you have it—billing and documentation for home-based outpatient PT demystified, even though there wasn’t as much mystery as many might assume. And with the potential benefit of more patients seeking treatment and completing their plans of care, home-based PT could be a good option for rehab therapy clinics looking to expand their offerings.