Physical therapy billing is complicated enough. When you throw Medicare into the mix, it becomes an even bigger headache. But when you consider the fact that, as of 2015, more than 55 million Americans receive Medicare coverage, every physical therapist is bound to contend with Medicare rules at some point. (Even cash-based PTs!) So, how can PTs prevent themselves from making Medicare billing blunders (aside from a world-class documentation and billing platform, of course)? One word: Communication. And to foster better communication between you and your Medicare patients right from the start, we strongly recommend asking the following questions during your first conversation with them—before you provide them with any treatment:

1. “Have you received Part A services this year?”

As John Wallace mentioned during this billing Q&A, as long as a patient is under the care of a home health agency, SNF, or acute care facility billing under Part A, Medicare will not reimburse for Part B services. And, as we explain in this WebPT Blog post, whenever a Medicare patient begins care in your practice, “make sure the patient is not also under the care of a home health agency—and if the patient was previously receiving home health care, verify that the patient has been discharged.” 

The best way to determine whether or not a patient is receiving concurrent Part A services is to ask the patient if he or she:

  1. is receiving care from any other provider (not just another rehab therapist), and
  2. can provide details about that care.

So, what if a claim is denied or recouped because the patient is currently receiving home health services? Can the provider bill the patient? Unfortunately, even if the patient erroneously tells you that he or she is not receiving home care, there’s not a whole lot you can do. You can try appealing your denial—and we definitely encourage you to do so if you have evidence to support your case—but there’s no guarantee that CMS will rule in your favor.

2. “Are you currently receiving—or have you received at any point during the current benefit period—Part B therapy services from any other provider?”

In some instances, a patient may be under two separate plans of care at two different practices within the same discipline. As we explain here, as long as both POCs meet Medicare’s standards, then Medicare will pay for services at both practices. That said, “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.” For that reason, it’s important to keep a close eye on the patient’s threshold usage so you know when to:

  1. affix the KX modifier to continue with medically necessary care, or
  2. issue the patient an ABN to provide treatment on a cash-pay basis.

Tracking the Therapy Threshold

For WebPT Members, tracking the therapy threshold is a little easier because the app will automatically calculate progress for them (and even account for services provided at other practices by allowing the practice to plug usage amounts into the system). But for everyone else, as we explain here, when determining how close a patient is to meeting (or exceeding) the threshold, $80 to $100 per visit is usually a pretty safe assumption. Providers can also obtain this info directly from CMS by:

  1. Electronically viewing “dollar amounts accrued toward the therapy limits on the ELGA or ELGB screens within the CWF (Common Working File) or on the HIQA screen for those providers who bill through fiscal intermediaries,” or
  2. Contacting your Medicare contractor directly and “requesting information regarding therapy services provided to a particular beneficiary. The amount accrued toward the financial limit is based on claim received date rather than the date of service. This is available via your MAC’s IVR system.”

3. “Are you currently receiving any home-based care?”

When you think of home health care, you probably think about Medicare Part A services—and for good reason! Typically, home health services are billed out under Part A. However, any services provided in a patient’s home as part of an outpatient plan of care—and billed under Part B—would count toward the physical therapy threshold. So, much like a PT should verify whether or not his or her patient is under any concurrent outpatient physical therapy plans of care, he or she should also verify whether or not the patient has received (or is receiving) any home-based services under Part B.

4. “Do you have any other insurance?”

Medicare can function differently when the beneficiary has private or commercial insurance in addition to his or her Medicare benefits, so you’ll want to confirm whether or not Medicare is his or her only insurance. If you have questions about whether or not Medicare should function as a secondary or primary payer to the patient’s insurance, you can contact the Coordination of Benefits Contractor (COBC) at 800-999-1118. Also, to clarify these differences and provide an overview of billing Medicare as a secondary payer, CMS has provided an in-depth fact sheet, which you can review here. (APTA members also have access to the APTA’s FAQ on Medicare as a secondary payer here.) If the patient’s other insurance is a Medicare Advantage or Medicare Supplement plan, refer to this blog post for billing guidance.

Here are a couple more things to note when it comes to Medicare in conjunction with another payer:

Working with Liability Insurers and Workers’ Compensation Plans

Typically, Medicare plans must function secondarily to no-fault insurers, liability insurers, and workers’ comp. However, according to CMS, if there is sufficient evidence that the other payer will not promptly pay, Medicare will conditionally cover the cost of services that these payer types would typically reimburse. Then, when the primary benefits kick in, the provider must repay Medicare for the conditional coverage.

Billing the Secondary Insurance for Non-covered Services

If the patient has met his or her deductible but has not signed an ABN before receiving services that Medicare doesn’t consider medically necessary, you cannot bill the patient. You can, however, attempt to bill the patient’s secondary insurance, but there’s no guarantee that the secondary payer will reimburse you either. As we explain here, “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, if the secondary payer also denies reimbursement—and the patient has accepted financial responsibility by signing an ABN—then you can bill the patient for the amount due.

5. “Do you understand your potential financial responsibility?”

In the past, we’ve written about discussing and explaining the patient’s financial responsibility with him or her prior to providing services. Not only does this strengthen the patient-provider relationship by promoting transparency, but it also helps prevent unexpected expenses on the patient’s end. Plus, having a discussion about what the patient may be financially responsible for creates an opportunity for patients to ask any other payment-related questions they may have.

According to compliance expert Rick Gawenda in this webinar, some common instances in which a Medicare patient might be held financially responsible for services are:

  • If the services are not medically necessary.
  • If the patient wants to receive non-covered services (e.g., fitness programs, wellness services, preventive care, athletic training, and supplies such as cold packs or Biofreeze).
  • If the services are not associated with a national coverage determination, meaning you expect the services to be denied (e.g., iontophoresis, cupping, and dry needling).

Issuing ABNs

As I mentioned earlier, in order for a patient to officially accept financial responsibility for Medicare-covered services that are deemed non-medically necessary in the patient’s specific case—that is, before you can collect payment directly from the patient—he or she must first sign an ABN. During the above-mentioned webinar, Gawenda offered these additional considerations when issuing ABNs:

  • They must be written in layman’s terms so patients can understand them.
  • They must be signed and dated by the patient or his or her legal representative—prior to your provision of the service.
  • At minimum, you must keep the original and provide a copy to the patient. 
  • You cannot provide blanket or incomplete ABNs.

So, there you have it: five questions outpatient PTs should ask every Medicare patient prior to evaluation and treatment. Got a few questions of your own? Drop them down in the comment section below!