Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum. As expected, we received more questions than our Medicare experts could answer during the live session, so we’ve provided the answers to the most frequently asked ones below. Don’t see the answer you’re looking for? Post your question in the comment section at the end of this post, and we’ll do our best to respond.

Billing Scenarios

Supervision and Extenders

Maintenance Therapy

Therapy Threshold



Cash Pay

Codes and Modifiers

POC Requirements




Billing Scenarios

Can therapists treat multiple Medicare patients simultaneously in the same treatment hour?

Yes, CMS permits providers to treat multiple patients at once, regardless of insurance type. To learn about the differences between one-on-one versus group services—as well as how to bill for them—I recommend checking out this post from the WebPT Blog.

What is the best possible way to bill when there are two Medicare patients scheduled along with a commercial insurance patient?

The answer, as is the case with so many Medicare questions, depends on the scenario. This is especially true for situations in which PTAs and aides are providing services, as Medicare’s rules around the use of extenders differ from some commercial payers’. 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. (Gawenda talks more about this here.)

Can we count time spent performing tests and measures for a progress note as part of the billed minutes for a timed procedure code such as 97110?

The time a therapist spends on things like ROM measurements, manual muscle testing, girth measurements, and pain assessments is billable; the time would simply be added into the minutes for the time-based services provided that day. For example, if you’re doing a physical performance test such as a Timed Get Up and Go, Berg Balance Test, or 6-Minute Walk Test, you could bill for that time under CPT code 97750. However, it’s important to understand that you cannot bill for the time you spend actually writing the progress report (more on that here), and you should not bill a re-evaluation simply because you completed a progress report.

I work at a clinic not contracted with Medicaid. When a Medicare patient has Medicaid as a secondary payer, do I have to submit claims to Medicaid, or can I file with Medicare only?

This depends on your state’s specific Medicaid rules, as Medicaid is a state-run program. We recommend reaching out to your state’s Medicaid contractor for more information.

Can PT students provide services to Medicare patients? Can they bill Medicare for those services?

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, PT students can treat, and write notes for, Medicare patients—but the qualified practitioner must direct the service, make the skilled judgement, and be responsible for the treatment delivery. The qualified practitioner must not be engaged in treating another patient at the same time. The student can even sign the note, but the clinical instructor or therapist must co-sign the note.

When we bill Medicare for an evaluation or reevaluation, we always receive denials for all the other treatment codes from those visits. Is there a way to bill Medicare—and receive payment for—both evaluative and treatment codes?

Yes. If you perform a re-eval and other treatments during the same visit, then you must apply modifier 59 to the re-eval code in order to receive payment for it. Otherwise, Medicare will only pay for the treatment codes. If you provide an evaluation on the same day as other treatments, no modifier 59 is required unless any of the treatment codes form edit pairs—in which case those pairs would require modifier 59 (given that the services were provided in a way that meets the criteria for modifier 59 use). To learn more about proper application of modifier 59, refer to this blog post.

How does Medicare work with direct access patients?

We actually wrote a whole article explaining how Medicare works with direct access patients. You can check it out here.

Can I bill for patient or family member education?

Yes, but there isn’t a specific code for patient or family member education. Instead, you’ll use the CPT code that best describes the type of education you’re providing. Here are three examples:

  1. If you spend time educating a shoulder patient on how to improve his or her range of motion, then you would bill for therapeutic exercise.
  2. If you educate a knee patient on how to use his or her walker and navigate steps, then you would bill for gait training.
  3. If you educate a patient’s parent or spouse on proper transferring procedures to move the patient from a bed to a wheelchair or a desk, then you would bill for therapeutic activities.

To learn more about billing for patient education, check out this post.

Do we have to bill Medicare if it’s the patient’s secondary insurance?

Yes. If Medicare is secondary, you must bill Medicare and follow Medicare regulations.

What if a Medicare patient asks us not to bill Medicare?

According to Gawenda, if the services you provided are covered services, then you cannot knowingly choose to not bill Medicare.

Is there a maximum number of units you can bill Medicare for a single date of service?

No. Medicare does not limit the number of units it will pay for in a day. It’s all based on medical necessity, the needs of the patient, and the quality of the documentation.

I currently work in an outpatient setting and am a “participating provider.” If I wanted to see Medicare patients outside of the clinic on the side (using my own independent business), can I also be a “non-participating provider?”

A provider cannot be a participating provider in one practice and a non-participating provider in another, because each provider’s NPI is attached to his or her Medicare credentials. The exception would be if the provider bills under a group NPI in one practice and his or her individual NPI in the other. To learn more about the difference between these two types of NPIs, read this blog post.

Can you go over how to bill for Medicare as a secondary payer?

CMS has provided an entire fact sheet on billing Medicare as a secondary payer, which you can review here. Additionally, if you are an APTA member, you can view the APTA FAQ on Medicare as a secondary payer here. Finally, you can confirm Medicare’s primary/secondary status for your patients by contacting the Coordination of Benefits Contractor (COBC) at 800-999-1118.

Can you explain co-treatment and how to properly bill Medicare for it?

As we explain here, “Therapists cannot bill separately for the same or different service provided to the same patient at the same time. Essentially, therapists must limit total billing time to the exact length of the session, so a therapist of one discipline may bill for the entire service or co-treating therapists of different disciplines may divide the service units.” Furthermore, in cases involving speech-language pathologists, the ASHA Leader states that because “SLPs usually bill treatment codes that represent a session (rather than an amount of time), and because Medicare has no published minimum/maximum session length, the SLP would bill for one untimed session.” The PT or OT would then bill “the timed treatment codes for the occupational or physical therapy.”

Can I choose to not bill or collect payment for services provided to Medicare patients?

If you are providing a Medicare-covered service, then the answer is no. As explained here, “if you provide a Medicare beneficiary with a service that is covered by Medicare, you must submit a claim to Medicare for that service. Most legal and compliance experts say that this mandate applies to all providers regardless of their relationship with Medicare.” As for services that are statutorily non-covered, you must be very careful about waiving or discounting costs for Medicare patients. (To learn why, check out this post.) In fact, if your practice engages in this practice, we’d recommend having your protocol reviewed by a legal expert.

Can you explain incident-to billing?

We actually have an entire blog post detailing incident-to billing.

How do you bill for iontophoresis, and is there a way to obtain payment for it?

According to this resource from the APTA, you should bill iontophoresis under CPT code 97033.
Unfortunately, there’s no surefire method for obtaining reimbursement. Medicare coverage for this treatment varies depending on your Local Coverage Determination (LCD). Check with your Medicare contractor to find out exactly where your practice stands.

Does Medicare allow locum tenens agreements for outpatient rehab therapy providers?

As we mention in this blog post, only PTs in medically underserved areas (MUAs), health professions shortage areas (HPSAs), and rural areas may take advantage of the type of arrangement formerly known as “locum tenens.” (As a side note, Medicare announced in 2017 that it would replace the term “locum tenens” with “fee-for-time compensation arrangements.”) For more eligibility details, refer to the Health Resources & Services Administration website.

Are patient rest breaks considered billable time?

No. As we explain in this blog post, patient rest breaks do not count as billable time.

How do I bill for dry needling, and will Medicare pay for it?

Check out this blog post to learn everything you need to know about billing for dry needling. If you want to find out if Medicare covers dry needling in your region, chat with your Medicare contractor.

Can you talk a bit about billing for devices such as braces, prosthetics, and durable medical equipment (DME)?

We actually wrote an entire post on billing for orthotic and prosthetic devices as well as DME. You can check that out here.

How do we successfully bill for treatments provided during the same visit for separate diagnoses related to separate body parts?

When treating a patient for two separate diagnoses on the same day, you’ll need to combine these services onto one claim. Furthermore, if more than one therapist is treating the patient on this date of service, both therapists’ treatments would have to be on the same claim. For additional information on co-treatment under Medicare, check out this blog post. Now, if you’re billing for two services that Medicare would normally consider linked or bundled—but you provided them for the treatment of separate injuries and/or body parts, thus warranting separate payment—then you would affix modifier 59 to the appropriate code, as explained in this blog post.

If we do not contract with the Medicare patient’s secondary insurance, can we bill the patient for the 20% coinsurance remaining?

According to this resource from AAPC, “If there is no contract between the insurance plan and the physician practice, the practice is not limited in what they may bill the patient.” That said, many states have implemented laws to protect patients against balance billing (you can see which ones here), so make sure you check your state practice act before attempting to collect.

Can I bill an evaluation code the same day as an L-code?

An evaluation CPT code should not be billed in cases involving an evaluation for the need for, and type of, orthosis if the provider billed an L-code. This is because the L-code payment covers the orthosis assessment, fitting, and if applicable, fabrication.

Would billing claims out of order (if we are waiting for a signature, for example) trigger an audit?

While it may not necessarily trigger an audit, any kind of aberrant billing practice could bring your practice unwanted attention from CMS—particularly if it happens consistently. We definitely advise submitting your claims in sequential order whenever possible.

Will CMS pay for telehealth therapy services provided to homebound patients in rural settings?

Although CMS has made some solid strides in the telehealth realm by loosening some treatment restrictions, Medicare doesn’t include PTs, OTs, or SLPs on its list of telehealth-eligible providers. So, at this time, Medicare won’t provide reimbursement for telehealth therapy.


Supervision and Extenders

Do patients with Medicare Advantage Plans—a.k.a. Medicare Part C—require direct supervision?

Typically, Medicare Part C plans follow the same supervision rules as Medicare Part B. However, because these plans are managed by private companies, it’s best to reach out to the payer directly (as well as review your state’s practice act) to confirm.

What is the definition of “general supervision” for a non-private practice setting?

As we explained here, “unless a state practice act says otherwise—therapist assistants may provide services in a skilled nursing facility or on behalf of a home health agency under the ‘general’ supervision of skilled therapist. General supervision means that the supervisor must provide initial direction and periodic inspection of the activity, but he or she does not necessarily need to be on the premises during every treatment. According to the APTA, the rules regarding supervision in an outpatient hospital setting are a little less clear, which is why the association recommends deferring to your state practice act to ensure compliance with all rules and regulations. Additionally, according to this CMS document, you may want to review your hospital’s by-laws.

Can an athletic trainer see a Medicare patient in a capacity similar to a PTA?

Athletic trainers can provide wellness services to Medicare beneficiaries; however, they are not eligible to provide services that fall outside their scope of practice (i.e., physical therapy) or to bill Medicare, as Medicare does not recognize athletic trainers as providers.

Are the rules of supervision for therapist assistants the same in every state?

Medicare has its own rules for assistant supervision, which apply across the US; however, you’ll also want to review your state practice act—and adhere to the supervision rules that are most stringent.

Does the proposed reimbursement reduction for services provided by PTAs and OTAs apply to Medicare Part A as well?

Nope. As stated in this resource from the NYPTA, the 85% payment differential will only apply to services provided by PTAs and OTAs under Medicare Part B.

Do you expect any other insurance companies to similarly restrict reimbursement for PTAs and OTAs?

Many insurance companies take their cues from Medicare, so it’s possible that others will also reduce reimbursement for PTA-provided services. However, there’s no way to know for sure until—and if—companies announce that decision.

In an outpatient private practice setting, do our PTs need to be onsite to supervise PTAs—or can they be available via telephone or videoconference?

As we wrote here, “according to the APTA, under Medicare, therapist assistants can provide therapy services in an outpatient private practice setting—as long as those services are performed under the direct supervision of a licensed therapist. Generally speaking, direct supervision means that the supervising therapist is physically present in the office—but not necessarily in the same room—and available to intervene if necessary at the time the assistant performs the services.”

Do Medicare Replacement plans follow the same supervision guidelines as Medicare for treatments provided by a PTA or tech?

This depends on the rules set for by the contractor, although most contractors follow the same rules as Medicare in most instances. We recommend reaching out to the contractor directly.

If a PTA is providing treatment to a Medicare patient in the patient’s home, does the PTA still require onsite PT supervision?

Yes, if the services are provided in an outpatient capacity. As Gawenda explains here, “If you are a private practice (this means you submit claims on a 1500 claim to the Medicare program), the therapist must be on the premise when an assistant is treating a Medicare beneficiary. So…you would not want to use PTAs to treat a Medicare patient in their home as an outpatient as the PT would need to be in the home with the PTA.”

In which settings do Medicare’s PTA supervision rules apply?

Medicare requires some kind of supervision of physical therapist assistants in all practice settings. However, the level of supervision varies from setting to setting. (CMS defines the various PTA supervision requirements between settings in this resource.) You should also check the supervision requirements for your state. (You can find a complete list here.) If your state’s practice act requires a higher level of supervision, then you’ll need to adhere to those guidelines.


Maintenance Therapy

Is there a PT-specific code for maintenance therapy?

Medicare covers—and always has covered—medically necessary maintenance therapy in outpatient settings other than comprehensive outpatient rehabilitation facilities (CORFs). There is no special code required, although your documentation should clearly explain why the patient requires continued skilled therapy care.

Can we treat Medicare patients on a cash basis for maintenance care related to issues like chronic low back pain?

Medicare covers medically necessary maintenance care, so you would continue to bill Medicare for any skilled services that are necessary to prevent further functional decline. You can learn more about Medicare’s coverage of maintenance therapy here.


Therapy Threshold

What’s going on with the therapy cap?

This past February, Congress repealed the hard cap on therapy services, but the $2,010 threshold—a.k.a. soft cap—is still in place. That means you still need to apply the KX modifier to medically necessary services that exceed this threshold going forward, although we’ll likely see a slight increase to the threshold amount year to year. You can read about the repeal—as well as how to handle claims exceeding the threshold—here.

How do I calculate the dollar amount to determine a patient’s progress toward the therapy threshold?

As Rick explained during the webinar, this dollar amount is based on the Medicare allowed amount for each CPT code—after Multiple Procedure Payment Reduction (MPPR) is applied and before the government’s 2.0% (net 1.6%) sequestration reduction is applied—not what you charge or receive from Medicare.

At what point should I begin adding the KX modifier to claims?

You only need to affix the KX modifier to claims that exceed the $2,010 threshold. Furthermore, you should continue using the KX modifier—as long as the services provided continue to meet Medicare’s definition of medical necessity—until the cap resets on January 1. For more information on the KX modifier, check out this post.

What happens if you think services are medically necessary, but Medicare denies the claim?

In that case, you’ll want to appeal the denial. You can learn more about Medicare’s appeal process here.

Is it common for Medicare patients to receive outpatient PT services beyond the soft cap?

Many patients—especially those with chronic or complicated conditions—require rehab therapy services that exceed the threshold, which Medicare will continue to cover as long as those services are medically necessary.

Does the patient’s $2,010 soft cap include other medical expenses outside of rehab therapy?

The therapy threshold applies only to Part B rehab therapy services. For 2018, Medicare’s soft cap is $2,010 for physical therapy and speech-language pathology combined and $2,010 for occupational therapy alone.

How do I successfully justify continued therapy treatment beyond the $3,000 threshold?

Medicare will continue to cover medically necessary services above the soft cap as well as the $3,000 threshold—for all patients. You simply must continue affixing the KX modifier to your claims—and supporting the continued need for skilled therapy services within your documentation.

Does Medicare automatically review claims that exceed the $3,000 therapy threshold—or is this a random process?

As Gawenda discussed during the webinar, the Medicare Access and CHIP Reauthorization Act of 2015—also known as MACRA—eliminated the requirement for manual medical reviews of all claims exceeding the upper threshold and replaced it with a targeted review process. Despite the fact that the review threshold was reduced from $3,700 to $3,000, we do not expect to see an increase in reviews. After all, Congress did not increase funding for claim reviews.

CMS’s Supplemental Medical Review Contractor—Noridian Healthcare Solutions, LLC—will be selecting claims above the threshold to review based on these criteria:

  • The provider has a high claims denial percentage.
  • The provider has a pattern for aberrant billing or questionable billing practices (for example, billing medically unlikely units of services in a day).
  • The provider is newly enrolled as a therapist—or has no previously submitted claims for therapy services.
  • The services are furnished to treat a type of medical condition.
  • The provider is part of a group that includes another provider whose claims were flagged for review.

Should we make it a rule to avoid going over the $3,000 targeted review threshold?

As Jannenga explained during the webinar, there are many therapists who see the soft cap and the target review threshold as stopping points, but that is absolutely incorrect. The question should always be, “Are continued services medically necessary for the patient?” If the answer is yes, then you should continue treating the patient and billing Medicare with the KX modifier affixed to your claims. And that’s true whether you’re exceeding the $2,010 threshold or the $3,000 threshold. Just make sure that your documentation supports the medical necessity of your services. For more details on using the KX modifier in the wake of the therapy cap repeal, review this blog post.

Does the therapy threshold apply to patients with progressive diseases such as Parkinson’s Disease?

The threshold applies for all patients—regardless of their condition. However, as noted previously, if services above the threshold are medically necessary, Medicare will continue to cover those services. Simply affix the KX modifier to claims above the threshold and continue to ensure your documentation supports the need for skilled treatment.

How will I know if CMS has chosen me for a targeted medical review?

If you’re flagged for a targeted medical review, CMS will reach out to you with a request for documentation that supports the claim(s) in question.

Is the 2019 PT soft cap amount available yet?

No, CMS will likely unveil the 2019 threshold amount later this year.

Should we perform an evaluation for all Medicare patients at the beginning of the new year to avoid issues with the KX modifier from the previous year?

The therapy threshold automatically resets at the end of the calendar year, so neither the threshold nor the KX modifier should dictate your decision to perform an an evaluation.

Does the therapy threshold apply to hospital-based outpatient clinic services?

According to this APTA resource, “The thresholds apply to all part B outpatient therapy services—including services provided by hospital outpatient departments.” This rule became effective once Congress passed the budget package back in February 2018.



Do I need to issue an ABN before providing non-covered services?

If you are providing services that Medicare never covers (e.g., fitness and wellness services), then you are not required to issue an ABN. However, you can choose to issue a voluntary ABN as a courtesy to the patient. You can learn more about voluntary ABNs here. Now, if you are providing services that Medicare usually covers—but that you believe Medicare may not consider medically necessary for this particular patient in this particular case—then you must issue a mandatory ABN in order to collect payment from the patient. For more on mandatory ABNs, refer to this blog post.

Can you explain how the GA modifier works when we issue an ABN?

When you issue an ABN for a service that Medicare usually covers—but that isn’t medically necessary for this patient in this particular case—then you would affix the GA modifier to the service on the claim, triggering Medicare to deny the claim. Once you receive the denial, you can collect payment from the patient.

When a patient fills out an ABN, what should I do with the form?

You must keep the original ABN on file and give a copy to the patient.

If we issue an ABN and the patient has a secondary insurance, can we bill the secondary insurance?

If you issued the ABN before providing services that are not medically necessary, then you can bill the patient and should not push charges over to the secondary insurance. If the services you’re providing are not normally covered by Medicare—and you’ve acknowledged that you will perform the services and the patient has acknowledged that he or she will pay for them via an ABN—then you would send the claim to Medicare and, after receiving the denial, send the claim to the secondary insurance.

How do I know if a service is medically necessary?

In 2011, the APTA adopted the Defining Medically Necessary Physical Therapy Services position, which states that “physical therapy is considered medically necessary as determined by the licensed physical therapist based on the results of a physical therapy evaluation and when provided for the purpose of preventing, minimizing, or eliminating impairments, activity limitations, or participation restrictions.” Furthermore, therapy treatment is considered medically necessary “if the type, amount, and duration of services outlined in the plan of care increase the likelihood of meeting one or more of these stated goals: to improve function, minimize loss of function, or decrease risk of injury and disease.”

All that being said, if Medicare has a question about the medical necessity of the services you provide, it’s on you to ensure your notes accurately and adequately describe what you did, why you did it, and what happened as a result. That’s why notes—specifically, the subjective notes—are so important. Be sure to always document what you did for the patient during each visit that he or she could not have done alone or at a fitness center (e.g., verbal instruction, technique correction, posture correction, biometric monitoring, and real-time exercise modification based on data). Also, make all of your goals functional, and document demonstrable progress toward each goal—even if the goal is to maintain. According to Gawenda, many providers could do a better job documenting self-care ADL deficits and teaching.

You mentioned using a GA modifier to indicate that an ABN is on file. We use the GX modifier when a patient has reached the therapy threshold and continued services are not medically necessary. What is the difference between GA and GX?

As we explain here, the GA modifier indicates that a required ABN is on file for a service or item not considered medically reasonable and necessary. The GX modifier indicates that a voluntary ABN was issued for non-covered services.

Where can I download an ABN form?

Official ABN forms are available on the CMS website in both English and Spanish.

We give our Medicare patients an ABN to sign during their initial evaluation to cover liability and home health services. Is that okay to do?

As Heidi and Rick discussed during the webinar, CMS does not allow providers to issue blanket ABNs. Instead, you should only issue an ABN:

  1. Before providing items or services that the therapist believes or knows Medicare may not cover; or
  2. Before providing items or services that Medicare usually covers but may not consider medically reasonable and medically necessary for this particular patient in this particular case.



What are the qualifications for required MIPS reporting? Will WebPT host a webinar covering MIPS requirements?

Medicare has not yet finalized the official qualifications for MIPS reporting in 2019, but we expect CMS to release those details in early November as part of its final rule. However, if CMS adopts the proposed guidelines for 2019, the majority of small practices will not be required to participate in MIPS. As we mentioned in a response to a comment on this post, “as it is currently proposed, MIPS will only be required for a select segment of practices that:

  1. Have more than $90,000 per year in Part B allowed charges;
  2. Have evaluated and/or treated more than 200 unique Medicare beneficiaries; and
  3. Have provided more than 200 covered professional services under the Medicare Physician Fee Schedule.”


WebPT will cover MIPS requirements during our year-end compliance webinar in December, so stay tuned for details. Gawenda Seminars & Consulting is also hosting a MIPS webinar, which you can register for here.

If a non-participating Medicare provider participates in MIPS, how is the payment adjustment applied?

According to this source, if you’re a non-participating provider who accepts assignment, the MIPS adjustment goes to your office. This is because, in this type of arrangement, Medicare pays the provider directly. If you’re a non-participating provider and you do not accept assignment, the payment adjustment is not applied “because payments are not made to the clinician.”

Should my practice participate in MIPS?

That’s a loaded question, as there are a lot of aspects of the MIPS program that providers must consider before making an educated decision. So, for a more in-depth MIPS discussion, be sure to attend our final rule webinar on December 12. Details will hit your inbox soon, so keep an eye out. Gawenda is also offering his own special MIPS webinar on December 18, which you can register for here.

Is MIPS the replacement for PQRS?

More or less; as we explain here, MIPS absorbed PQRS along with the Meaningful Use (MU) and Value-based Modifier (VM) programs. But, it’s not a direct, one-to-one replacement.


Cash Pay

Can Medicare patients choose to pay cash for their PT services instead of going through Medicare?

Medicare patients can choose to pay cash for services that Medicare never covers (e.g., fitness or wellness programs) or services that Medicare does not consider medically necessary, but there some caveats based on your relationship with Medicare:

  • If you are a participating provider, you must bill Medicare for Medicare-covered services—even if you expect Medicare to deny reimbursement for those services.
  • If you are a non-participating provider, you can collect payment from the patient upfront for Medicare-covered services, but you must submit the claim to Medicare; CMS will then reimburse the patient.
  • If you have no relationship with Medicare, you may not provide Medicare-covered services to Medicare beneficiaries.

For more detailed information on the rules around Medicare and cash pay, check out this three-part blog series:

Can our PT clinic provide supervised exercise services to Medicare patients on a cash basis if those services are not considered skilled therapy?

In most cases, physical therapy practices can charge patients directly for services that Medicare never covers, including wellness and fitness services.

If a patient has achieved his or her functional goal and therapy is no longer medically necessary—but the patient wants to continue receiving therapy care—can we treat the patient on a cash basis?

Yes. However, if the services are usually covered by Medicare, then you would need to issue an ABN and submit the claim to Medicare with the GA modifier, which signals that the services are not medically necessary. Once you receive a denial, you can then collect payment directly from the patient. Now, if the services you’re providing are not considered “skilled therapy” and thus, are never covered by Medicare, then you can accept cash payment from the patient without having an ABN on file. To learn more about the proper use of ABNs, check out this blog post.


Codes and Modifiers

Will Medicare cover outpatient lymphedema therapy? If so, which billing codes should I use?

Currently, Medicare only covers certain portions of physical therapy treatment for primary lymphedema. For more information, check out this resource from the APTA and this one from Noridian.

I am confused as to how many functional limitation reporting codes I need to submit at each required reporting interval. Can you clarify?

As we explain here, “To successfully complete functional limitation reporting, you must designate a patient’s primary functional limitation—in other words, the main reason the patient is seeking therapy—and document it along with the severity of the limitation (current status and projected goal status) at the patient’s initial examination and at minimum every tenth visit or progress note. Then, when you discharge the patient, you must report the discharge status and projected goal status.”

So, at each visit for which reporting is required, you should submit two G-codes and two corresponding severity modifiers (one for current status and one for projected goal status). Then, at discharge, you would report G-codes and corresponding modifiers for discharge status and projected goal status.

The only time you would report all three G-codes at once is if you were completing a one-time visit (i.e., for a patient who will not return for additional therapy).

When should I use group treatment codes instead of one-on-one treatment codes?

We actually wrote an entire blog post detailing the differences between providing and billing for one-on-one services and group services. You can check it out here.

What is the best way to document each type of therapy for time-based services?

To indicate the type of therapy you’re providing for each service, you would affix the therapy modifiers GP, GO, or GN (for physical therapy, occupational therapy, or speech-language pathology, respectively).

Which place of service code should an outpatient rehab facility use?

You can find a list of place of service (POS) codes here. For outpatient rehab facilities (ORFs), you would want to use POS code 11, as this covers any “location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, or intermediate care facility (ICF), where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis.”

Has there been a change in the use of modifier 59 when billing 97140 in conjunction with evaluation/reevaluation codes?

As far as we know, there has not been a change. You can use the 59 modifier on the 97164 and 97140 codes so long as the reevaluation was medically necessary and was separate and distinct from the therapeutic procedure.

How should I code group therapy for Medicare patients? What if I’m treating a group that includes both Medicare and non-Medicare beneficiaries?

As Gawenda explained during the webinar, the CPT code for group therapy is 97150—and that’s true regardless of the insurance type. Remember, CPT code definitions—including whether a service requires one-on-one patient contact—are developed by the American Medical Association (AMA) and apply to all payers. So if, for example, you’re providing group therapy to one Medicare patient, one Aetna patient, and one BCBS patient, then you would charge one unit of group therapy (97150) for each.

What’s going on with the X modifiers?

The so-called “X modifiers”—XE, XS, XP, and XU—were introduced as an eventual replacement for modifier 59. As of today, though, Medicare still does not require them. As Gawenda explained during the webinar, you can use them in lieu of modifier 59 if you want—but you are not required to do so when billing under Medicare Part B. Gawenda recommends continuing to use modifier 59, because he is not sure all MACs have built the X modifiers into their automatic claims processing systems. For more information on the proper application of modifier 59, check out this blog post.

When do I use modifier 59?

We wrote an entire post on this here. You can also check out the edit pair chart here.

We have gotten some denials for disallowed Medicare diagnosis codes. Is there a list of these somewhere that we can refer to so we don’t use them in the future?

All valid ICD-10 codes are technically “billable”; however, there is no cut-and-dried list of diagnosis codes that will generate Medicare reimbursement.

What modifiers are necessary to distinguish habilitative care from rehabilitative care?

As we explain here, “As of January 1, 2018, modifiers 96 and 97 replaced the SZ modifier, which providers were previously using to indicate habilitative services (per CMS transmittal 3940):

  • Providers must now use modifier 96 (following the CPT code) to identify habilitative services or procedures that could be considered either habilitative or rehabilitative.
  • Modifier 97 serves the same purpose for rehabilitative services that could otherwise be considered either habilitative or rehabilitative.”


POC Requirements

What are Medicare’s requirements for plan of care (POC) recertification? Does the physician need to sign off on the POC once every 90 days or whenever there is a significant change in the patient’s functional status?

The answer is “both.” As we mention in this blog post, “Medicare requires that therapists recertify the POC within 90 days of the initial treatment or if the patient’s condition changes in such a way that the therapist must revise long-term goals—whichever occurs first.”

What happens if the physician signs the POC but does not date it?

You should make reasonable attempts to secure a date along with the signature. According to this CMS resource on signature guidelines, omitting the date could trigger a medical review. However, if your documentation shows that you made reasonable attempts to secure a full signature and date, you should be just fine.

Should I stop treating a patients if I don’t obtain a POC signature within the 30 days?

As we explain in this blog post, you can begin treating patients before you obtain POC certification. However, you should only do so only if you’re confident you can secure the certification within 30 days. Otherwise, “the plan is considered ‘delayed,’ and additional documentation is required to explain why it took more than 30 days to get certified and…the reasonable attempts [that were] made to get the plan certified.”

Can I still submit claims if the physician has not signed the plan of care?

As stated in the aforementioned blog post, “if the conditions of payment are not met, Medicare will not pay for the services.” Additionally, “submitting a claim to Medicare without a certified POC on file is a big no-no that could increase your risk for an audit.” So, we highly advise against this.

Do I need to obtain an updated physician’s prescription every 30 days?

As we mention in this post, “Medicare does not require patients to obtain physician prescriptions for PT services.” However, the physician must certify the physical therapy plan of care within 30 days of the PT establishing it. The same article goes on to say that “the PT must recertify the POC ‘within 90 calendar days from the date of the initial treatment,’ or if the patient’s condition evolves in such a way that the therapist must revise long-term goals—whichever occurs first.”

What is the procedure for delayed certifications of the plan of care after 60 days? Do we need the physician to sign off on an explanation as to the reason for the delay?

First, you should continue trying to obtain the signature—even if it’s late. And per Medicare, for delayed signatures, you simply need documentation demonstrating that you made reasonable attempts to secure the signature on time—a fax log, for example. So, make sure you keep that on file in the patient’s record.

If the POC expires, does the patient need to bring in a new script? Does the therapist have to create a new plan of care and request the physician’s signature on it?

When the plan of care expires, the therapist must obtain the physician’s signature to recertify it. Now, if the certification lapses before you are able to recertify the POC, make sure you update it immediately and provide an explanation for the delay. If there is any medical evidence for the delay, make sure you include that as well.

Can I bill Medicare for an initial evaluation without a physician signature?

Yes, because Medicare does not require you to have a signed order to perform—and bill for—an initial evaluation. However, if you decide based on your initial eval that physical therapy is appropriate, you must have a physician sign the POC within 30 days. Also, be sure to check your state practice act to verify its direct access requirements; then, adhere to the most stringent rules.

How should we handle a patient who becomes Medicare-eligible mid-episode of care? Would the patient need a new POC?

In this type of scenario, you have to establish new POC, because it is considered a new episode of care. So, that visit becomes visit number one for reporting purposes (you must begin submitting functional limitation reporting G-codes once you establish the Medicare POC). And while you’ll need to evaluate the patient to complete the required reporting, you should not bill for an evaluation. Otherwise, you will continue treating the patient as normal.

How long is a physician’s script valid?

Medicare doesn’t require a physician’s order. However, Medicare does require a signed plan of care, which must be recertified every 90 days, at minimum. (As a side note, there’s no hard-and-fast rule for script renewal for non-Medicare payers.)

Can an out-of-state physician certify the POC for a patient I am treating?

According to this Florida Physical Therapy Association page, “There is nothing explicit in the Medicare Policy Manual that specifically says ‘a PT can have a plan of care certified by an out-of-state physician.’ Medicare does state that practitioners must first meet the requirements of their state licensure law, and defers to state law for any restrictions. If a state licensure law is more restrictive than Medicare, then the practitioner needs to follow that first.”

How often do I need to complete a progress note—and can I bill it as a re-eval?

For Medicare Part B patients, you must complete a progress note every ten visits—unless your state practice act sets forth a more restrictive reporting requirement. As explained here, you cannot bill for a re-eval when you complete a routine progress note; in order to bill for a re-evaluation, there must be a change that requires further evaluative action. If you’re simply taking progress measurements or performing outcomes measurement tests—and the patient is progressing through his or her POC as expected—then there is no reason to charge for a re-eval. As a side note, progress reports must be completed by a therapist—not an assistant or student.

What’s going on with functional limitation reporting (FLR)?

As explained here, CMS has proposed to end FLR at the conclusion of 2018. We expect this to be implemented, meaning that as of January 1, Medicare will no longer require FLR on Part B claims. However, this only applies to Medicare Part B, so if you have other payers that require FLR, you will still have to report until the payer indicates otherwise.

If we do not have a signed plan of care, can we treat the patient?

Medicare requires physician-signed plans of care within 30 days. So, while you could begin treatment before having a certified POC on file, you should be confident that you’ll be able to collect that certified POC within 30 days. It’s important to remember that the POC does not have to be signed by the patient’s primary care provider; instead, you can send the patient to a PT-friendly physician in your network for the signature.

If a Medicare patient does not come back for his or her last visit, can I complete a quick discharge (which is an option within WebPT) since I was unable record the patient’s final OMT scores and measurements?

If a Medicare patient does not return to therapy for a formal discharge, you can complete a quick discharge note within WebPT to close out the case. After 60 days, Medicare will automatically discharge the episode of care.

How do I find out when a physician signature is required to treat a patient in my state?

Please defer to your state practice act. Then, adhere to the rules—from your state practice act or Medicare—that are most stringent.

Does Medicare require both a signed POC and a signed IE, or does just a signed IE work?

Medicare requires a physician-signed POC; if the POC is clearly defined within the initial evaluation, then a signed IE should suffice.

What are the current regulations regarding the necessity of a physician referral?

Medicare does not require patients to obtain a physician referral in order to receive an initial evaluation from a physical therapist. However, Medicare does require physical therapists to obtain a physician-signed and dated plan of care within 30 days.

What if I have trouble getting the patient’s physician to sign the POC?

As we explain here, “This is where your physician networks can come in handy, as you can send patients to a PT-friendly physician to obtain certification.”

Can we use ranges for the frequency and duration of treatment?

As noted in this resource, the plan of care must incorporate several elements, including:

  • “Frequency of treatment (number of times per week; do not use ranges)
  • Duration of treatment (length of treatment; do not include ranges).”

If a patient does not attend a scheduled session, does that visit apply to the total visit count (for FLR purposes)?

No. You should remove that visit from the schedule to ensure your total count remains accurate.

Are there clear rules about writing functional goals for a POC?

Although there don’t appear to be any hard and fast rules about writing functional goals, this resource has some excellent suggestions about functional goal-writing. The authors suggest following the SMART formula, meaning your final goal should be specific, measurable, achievable, relevant, and time-oriented.

If a patient has not been seen for more than 60 days, but returns for the same case, do we need to perform a new initial evaluation or a reevaluation?

As we mention in this blog post, if a patient stops coming to therapy and returns for the same case after more than 60 days, you should perform an initial examination and treat it as a new case.



How do we go about getting our new practice credentialed with Medicare?

You must complete an enrollment application through CMS.

If Medicare audits my claims, will it also audit claims submitted to Medicare Advantage carriers?

Medicare handles audits for Medicare Advantage (MA) plans a bit differently than it does for original Medicare (and as explained here, there’s actually been a big push to improve MA audit processes). You can learn more about MA audits on this CMS resource page.

Does Medicare provide any free resources PTs can access to stay current with outpatient Medicare rules, requirements, guidelines, and changes?

Medicare provides many free resources for clinicians. WebPT also has a free definitive guide to Medicare available on our website.

What are some common documentation errors, oversights, or omissions that could be considered red flags for Medicare patients receiving outpatient PT services?

The most common documentation issue that could trigger an audit would be documentation that is not defensible; in other words, documentation that does not support the medical necessity of the services in question and the patient’s need to continue receiving skilled care. Your documentation should always clearly articulate the patient’s story, the services you provided, and your justification for doing so.

How many chart audits should a facility or private practice complete on a yearly, quarterly, or monthly basis to maintain compliance?

Self-audits are incredibly helpful for pinpointing any bad, non-compliant habits your practice may have picked up over time. Jannenga recommends conducting self-audits on a monthly basis, and the APTA recommends conducting self-audits using “20 or more charts per clinician.”

How much is the 2019 Medicare deductible?

The 2019 deductible for Medicare Part B will be $185. The 2019 inpatient hospital deductible for Medicare Part A will total $1,364.

Do third-party Medicare providers—such as Aetna—need to reimburse and follow Medicare guidelines?

Usually, Medicare-approved third-party providers adhere to Medicare guidelines. However, if in doubt, it’s always best to check with the payer directly.

Can we charge Medicare patients no-show fees?

According to this AAPC resource, “Under the current guidelines, Medicare allows a no-show fee as long as the practice:

  • 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.”

What is the difference in reimbursement if you are participating provider versus a non-participating provider?

As Jared Carter writes in this blog post, “Non-participating providers are paid 95% of the normal physician fee schedule amount.”

When is the cutoff to change our status to “participating?” We are currently non-participating.

According to the American Academy of Family Physicians, providers “wishing to change their Medicare participation or non-participation status for a given year are usually required to do so by December 31 of the prior year.”

If a Medicare patient is in an accident involving motor vehicle or workers’ compensation insurance—but that patient started PT with his or her Medicare benefits while waiting for the other insurance to kick in or be authorized—does the provider have to refund Medicare after the other insurance kicks in?

Per this Medicare resource, Medicare will conditionally cover services that no-fault insurers, liability insurers, and workers’ comp plans would typically pay if there is evidence that the other insurer will not provide prompt payment. That said, Medicare plans must always function as secondary to these payer types, so when a settlement, judgement, or award is complete, you must repay Medicare for the conditional coverage.

Holy Medicare, Batman—that’s a lot of questions and answers! As we mentioned in the introduction to this post, if there’s anything we missed, be sure to leave your question in the comment section below, and we’ll get you an answer.