Once upon a time, there was a clinic that never had a single denied claim or failed audit. This clinic prioritized ensuring compliance with Medicare rules and regulations just as much as delivering top-notch patient care and shipping clean claims. This practice was so successful, in fact, that employees never had to stress about the threat of Medicare fines, which meant they could focus all of their energy and attention on creating an incredible patient experience (and maybe even squeeze in some creative marketing). What made this practice so special, you ask? Read on to find out.

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Chapter 1: Insurance Verification

In this fantasy practice (which I’ve dubbed “The World’s Most Compliant PT Clinic”), the team running the front desk understands their role in ensuring clean, compliant claims. Not only do they faithfully gather patients’ insurance information and ensure that information is entered correctly into the EMR (which prevents rejections), but they also verify every patient’s insurance benefits. More importantly, they do so before patients ever set foot in the clinic, because they obtain patient insurance information over the phone or via a secure client portal. And they don’t stop with a single initial verification; they continue re-verifying each patient’s benefits on a monthly basis. This ensures the deductible payment totals—as well as any changes to collectibles or benefit coverage—are up to date.

In the case of Medicare patients, the front office staff at The World's Most Compliant PT Clinic double-check each beneficiary’s progress toward the therapy threshold for that year—even if he or she has not been seen in that practice before. That’s because they know there’s always a chance the patient sought rehab therapy services at a different practice prior to starting treatment at theirs. Furthermore, they realize how important it is to verify cap usage later on down the line—particularly with respect to KX modifier application.

Chapter 2: Medical Necessity

The next part of our story takes us onto the treatment floor. Over the past couple of years, Medicare has put a lot of effort into clarifying its definition of medical necessity—especially as it relates to maintenance care. On the one hand, Medicare has cleared pathways between patients and necessary maintenance treatment. However, the therapists at The World’s Most Compliant PT Clinic know that’s no reason to rest on their laurels; otherwise, they leave their documentation vulnerable to increased scrutiny. That’s why these PTs are all about documenting defensibly, which means they don’t merely justify medical necessity with their documentation. They also:

  • thoroughly evaluate the patient to assess medical necessity and create the best evidence-based treatment plan based on the patient’s goals;
  • provide Medicare patients with an Advance Beneficiary Notice of Noncoverage (ABN) before rendering covered services that aren’t medically necessary; and
  • never knowingly submit claims for covered services they believe are “reasonable and necessary” without first ensuring their documentation proves medical necessity.

KX Modifier

As we all know, the therapy cap is quote-unquote “gone." However, Medicare only pays for services beyond the $2,040 threshold (a.k.a. the “soft” cap) if those services are medically necessary—something the rehab therapists at our uber-compliant clinic know all too well. So, once a Medicare patient exceeds that limit, the therapists apply the KX modifier, and they only do so after the patient goes over the threshold—never before. (Going back to the previous section, this is why the front office staff make it a point to verify cap usage before Medicare beneficiaries begin treatment.) Therapists’ decisions on whether or not to exceed the threshold are based on whether (1) their patients would medically benefit from continued therapy and (2) treatment beyond the cap would help those patients meet their functional goals—not on fear of having their KX usage audited. And in the event that treatment beyond the threshold is not medically necessary, the therapist either discharges the patient or issues an ABN so the patient can continue attending therapy on a self-pay basis. 


As I mentioned above, the therapists in the World’s Most Compliant PT Clinic know they must always issue an Advance Beneficiary Notice of Noncoverage before rendering services that they either (a) know are not medically necessary or (b) don’t expect Medicare to cover. More importantly, they only issue ABNs when they’re supposed to—which means they never:

  • issue blanket ABNs, or
  • issue ABNs after they’ve billed Medicare for the non-covered service.

At each visit, the therapists talk to their patients to promote transparency. That conversation covers everything from treatment plan details and the reasoning behind each treatment, to which services are and are not covered by insurance. When applicable, they also discuss the patient’s financial responsibility and whether he or she might need to sign an ABN. In the event that the patient does need a signed ABN, the front office staff educates the patient on the notice, has the patient sign it, and then notifies the therapist that treatment can proceed.

Chapter 3: Plan of Care

Next, our compliance-conscious therapists pay special attention to proper plan of care (POC) documentation. First, they demonstrate that the patient is under the care of a physician by obtaining a physician's signature on the therapy plan of care. This is where communication between the front office team and the clinical team (again) becomes crucial, as the therapists can start treatment while the front office pursues physicians’ signatures. Per CMS, therapists have 30 days from the date of the initial eval to get a physician to sign off on the POC. However, you can’t always assume a physician will return the signed document to you within that time frame, so the front office staff keep a record proving they made reasonable attempts to obtain signature—just in case they never receive it. This lowers their risk of penalty if their documentation is ever called into question.

Additionally, while functional limitation reporting ended this past January, the therapists at the World’s Most Compliant PT Clinic still complete progress notes at every tenth visit for all Medicare Part B patients. That’s because the progress note requirement isn’t tied to the now-defunct functional limitation reporting program. Plus, these therapists understand the importance of assessing their patients’ progress at regular intervals and updating the patient’s file accordingly.

Chapter 4: Assistant Supervision

Even the assistants at this practice value compliance, and that makes a huge difference for the therapists. In outpatient therapy practices, therapist assistants can render services—as long as they do so under the direct supervision of the appropriate provider (PT, OT, or SLP). (Note that this does not include techs or students, as they are not considered licensed providers.) CMS defines “direct supervision” as a situation in which the supervising physical therapist is onsite and in the office at the time the assistant performs the service. However, the therapist does not need to be in the same room.

Because they are practicing under a patient-centered care model, the entire staff embraces a team approach to care. Upon initial evaluation, the therapist introduces the patient to everyone who may be part of his or her treatment plan—including assistants. And whenever an assistant completes a service, our supremely compliant therapists include language in their documentation affirming that they reviewed the plan of care with the assistant—something co-signing does not necessarily imply.

Chapter 5:  Direct Access

In this clinic, all staff members are keenly aware of the direct access laws in their state. They also understand that Medicare allows for the initial exam to be completed without a physician’s referral—and they schedule patients accordingly. Therapists then (1) complete the initial evaluation, (2) document thoroughly (as discussed above), and (3) educate the patient on direct access and (if applicable) the need for a physician-approved treatment plan. And in the event that a patient needs a physician signature—but can’t immediately get in to see his or her own physician—the team at the World’s Most Compliant PT Clinic knows just what to do. Because the practice has tight relationships with a variety of PT-friendly physician offices, the patient can easily schedule a visit to undergo further assessment and get the treatment plan approved. In fact, whenever this situation arises, the front office staff at the World’s Most Compliant PT Clinic call the physician selected by the patient to get a visit scheduled ASAP—preferably before the patient has finished his or her physical therapy appointment.

Chapter 6: Cash Services

Finally, because this clinic is pretty business savvy, it also offers wellness services for which many patients opt to pay out of pocket—even Medicare patients! And because Medicare doesn’t typically cover most therapy-related wellness or post-care services, Medicare beneficiaries can pay out of pocket for things like massage, yoga, Pilates, or other fitness classes. However, some preventive and wellness services (like annual wellness visits) are considered covered services—and providers cannot accept cash payment from Medicare beneficiaries for services that are covered by Medicare. So, before accepting cash from a Medicare patient, this clinic always verifies whether or not the service in question is something Medicare will pay for. And when they do accept cash for those services, they always issue an Advance Beneficiary Notice of Noncoverage (ABN) to the patient to keep on file before collecting the payment.

Epilogue: A Final Thought

As a PT myself, I know staying totally compliant 100% of the time is easier said than done, and it isn’t always realistic. Furthermore, I know we created this scenario in the bubble of the clinic’s four walls, when in reality there are many outside forces at work that impact the speed and efficiency of the above sequences. Still, it’s the goal you should be striving for—and having a documented compliance policy in place will go a long way. Even if you mess up here or there, having (1) a written and accessible plan and (2) regular discussions and education sessions with your staff can help foster a compliance-focused culture in your practice. Better yet, think about implementing a full-fledged staff compliance training program so you can empower each individual employee to take ownership of the clinic's compliance—and to hold their teammates accountable. 

Now, I know you may be thinking that the best solution would be having an EMR that takes care of it all for you, so you don’t even have to think about compliance. And while top-notch EMR systems like WebPT implement as many compliance stopgaps and alerts as possible, the truth is that your EMR can’t function as the be all, end all of compliance in your clinic. When it comes to compliance, the responsibility ultimately rests with the clinic—the owner and everyone else on staff. That’s why it's important to be cognizant of all the places you should be focusing your attention (and to ensure you have safeguards in place that reduce your risk of a major violation). Add in a team who values compliance just as much as you do, and you’ll be well on your way to living happily ever after.

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