If you’re a rehab therapist who works with Medicare beneficiaries, chances are you’ll find yourself performing a service that isn’t covered by their insurance. When that happens, you could find yourself in a billing predicament—if you don’t take the proper steps, that is. What are those proper steps? Read on to find out.

WebPT Outcomes - Regular BannerWebPT Outcomes - Small Banner

Which services does Medicare not cover?

To start, it’s important to identify which services Medicare won’t cover. Typically, Medicare denies coverage for one of four reasons (and the same is often true for commercial payers as well). Here are the categories of noncoverage:

1. Medically Unreasonable or Unnecessary Services

Medicare does not cover services that fail to meet CMS’s definition of medical necessity. To be considered medically necessary, the services must meet specific criteria defined by national coverage determinations (NCDs) and local coverage determinations (LCDs). As we explain here, “in most cases, the medical necessity of services is determined based on:

  • Whether the cost of treatment is reasonable considering the patient’s chances of reaching a desired level of relief or functional improvement.
  • Whether the treatment will mitigate the patient’s risk of suffering an even worse outcome if the current condition is left untreated.”

2. Non-Covered Services

Generally speaking, Medicare does not cover the following services:

  • Custodial care
  • Services provided outside of the United States
  • Services required as a result of war
  • Services and items for personal comfort
  • Routine checkups
  • Cosmetic surgery
  • Services furnished by the beneficiary's household member or immediate family member
  • Dental services
  • Services furnished in a SNF setting not delivered directly under the arrangement of the provider
  • Certain services and devices for foot care
  • Investigational services
  • Services related to or required as a result of a non-covered service

3. Bundled Services

Per CMS, “Medicare does not pay [for] services and supplies denied as bundled or included in the basic allowance of another service, such as:

  • Fragmented services included in the basic allowance of the initial service
  • Indirect prolonged care
  • Physician standby services
  • Case management services, such as beneficiary telephone calls
  • Supplies included in the basic allowance of a procedure.”

4. Services Reimbursable by Other Organizations

Furthermore, Medicare will not pay for services:

  • that are reimbursable under the Medicare Secondary Payer Program;
  • paid for by a government entity;
  • the beneficiary, another individual, or an organization has no legal obligation to pay for;
  • defective items covered under warranty.

Pro tip: While these four categories describe non-covered services, there are exceptions to each one. For this reason, you should always review any applicable exceptions before billing a patient for what you presume to be a non-covered service.

How can you collect payment for non-covered services?

Here’s the short answer: unless the patient has a secondary insurance, he or she will likely end up footing the bill. But before you can collect, you must make sure you’re dotting your i’s and crossing your t’s. And that means issuing an Advance Beneficiary Notice of Noncoverage (ABN).

Have the patient sign an ABN.

As we explain in this blog post, “An ABN is a form practitioners use to notify a Medicare patient that Medicare might not cover the therapy services he or she is about to receive,” and providers must issue an ABN before rendering services that are usually covered by Medicare, but are not expected to be paid in a specific instance. The purpose of an ABN is to ensure that a patient makes an informed decision about whether he or she should receive the service, thus accepting financial responsibility should Medicare not pay. That’s why it’s crucial to issue the ABN prior to rendering the service. (But resist the urge to issue a blanket ABN!) Furthermore, if the provider fails to issue the ABN in advance, the patient will not be financially responsible for the service. Once the provider has obtained a signed ABN, he or she must provide the patient with a copy and retain a second copy with the patient’s medical record.

Ship the claim to Medicare.

Once you’ve obtained a signed ABN—and the patient has accepted financial responsibility for a service—add the service onto the claim with the correct CPT code, required service modifiers (e.g., GP for physical therapy, GO for occupational therapy, and GN for speech-language pathology), the GA modifier (which indicates a signed ABN is on file).

Pro tip: If the service is statutorily excluded or is not covered by Medicare benefits, you would affix the GY modifier instead of the GA.

Collect the patient’s payment.

Next, your Medicare contractor will process the claim and send you an Explanation of Benefits (EOB), which will indicate the non-covered charges are the patient’s responsibility. From there, you can charge the patient for this service or send the charges to the patient’s secondary insurance (if applicable).

And finally, remember never to bill statutorily non-covered services under a payable code, as this is considered fraudulent.

Pro tip: Per this CMS resource, for services that are never covered by Medicare, you do not need to submit a claim to your Medicare contractor unless the patient has a secondary insurance that might cover the service. In that case, you would need the Medicare denial in order to submit the claim to the secondary payer.


So, there you have it: your guide to getting paid for services not covered by Medicare. Got any questions for us? Drop them in the comment section below!

  • FAQ: Unwrapping MIPS and the Final Rule: How to Prepare for 2019 Image

    articleDec 14, 2018 | 38 min. read

    FAQ: Unwrapping MIPS and the Final Rule: How to Prepare for 2019

    Earlier this week, Heidi Jannenga, PT, DPT, ATC, WebPT President and Co-Founder, and Dianne Jewell, PT, DPT, PhD, FAPTA, WebPT Director of Clinical Practice, Outcomes, and Education, hosted an hour-long webinar that unwrapped the many layers of MIPS and the 2019 physician fee schedule. Unsurprisingly, tearing through the layers of CMS’s latest gift revealed a crush of questions—many of which our experts didn’t have time to fully address. So, we compiled the most frequently asked ones for …

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    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 …

  • Should PTs, OTs, and SLPs use the New X Modifiers? Image

    articleNov 7, 2018 | 4 min. read

    Should PTs, OTs, and SLPs use the New X Modifiers?

    When it comes to Medicare, a lot can change in four years—whether it be the rise and fall of functional limitation reporting or answers to questions like, “Do outpatient rehab therapists have to report MIPS?” (You can get that answer here , by the way.) So, when CMS introduced the X modifiers back in 2015 and told PTs, OTs, and SLPs they wouldn't have to use them, anyone familiar with Medicare rules knew that advice was subject …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • 59 vs. 25: Which Modifier to Use–and When Image

    articleDec 20, 2018 | 3 min. read

    59 vs. 25: Which Modifier to Use–and When

    Rehab therapy billing : It’s a total numbers game. Between CPT codes and billing modifiers , knowing which digits belong on a claim is no simple task. After all, rules seem to change with the seasons, and they often vary from payer to payer. Here on the WebPT Blog, we receive a lot of comments and queries in response to these ever-changing rules, and one of the hottest points of confusion these days is the difference between …

  • Double Duty: How to Bill for PT and OT on the Same Day Image

    articleNov 12, 2018 | 6 min. read

    Double Duty: How to Bill for PT and OT on the Same Day

    In many cases, physical therapy and occupational therapy go together like peanut butter and jelly. PTs and OTs often share similar goals and interventions, treat the same types of patients in the same settings, and get confused by the billing rules that apply to our respective specialties. This confusion leads to quite a few questions, including this head-scratcher: how does one bill for OT and PT provided to a single patient on the same day? While the …

  • The Ultimate ICD-10 FAQ: Part Deux Image

    articleSep 24, 2015 | 16 min. read

    The Ultimate ICD-10 FAQ: Part Deux

    Just when we thought we’d gotten every ICD-10 question under the sun, we got, well, more questions. Like, a lot more. But, we take that as a good sign, because like a scrappy reporter trying to get to the bottom of a big story, our audience of blog readers and webinar attendees aren’t afraid to ask the tough questions—which means they’re serious about preparing themselves for the changes ahead. And we’re equally serious about providing them with …

  • Founder Letter: 3 Ways Your Practice is Losing Money Image

    articleMay 5, 2016 | 7 min. read

    Founder Letter: 3 Ways Your Practice is Losing Money

    Much like the patients you treat, your practice can appear healthy on the outside despite significant internal issues. And when those issues are money-related, the consequences can be deadly. If your practice already is in the red, you know you’ve got some pretty serious cash flow problems. But even if you’re in the black every month, you may still be washing dollars down the drain. While there are myriad ways your practice might inadvertently be losing revenue, …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.