The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP

Introduction

In October, we hosted a webinar dedicated to the most common Medicare misconceptions. We received a lot of questions from the audience—so many, in fact, that we’ve organized them all into one huge FAQ. Scroll through and check them out, or use the link bank below to skip to a particular section.

The Therapy Cap

If a patient reaches the therapy cap ($1,960) and continued treatment is not medically necessary, but the patient wants to keep coming to therapy anyway, what should I do?

If you feel your services are no longer medically necessary, but the patient wishes to continue therapy, then you can provide therapy to the patient on a self-pay basis (i.e., have the patient pay out-of-pocket). However, you must first issue the patient an ABN—as explained in this blog post—and apply the GA modifier. This should prompt Medicare to deny the claim, at which point you can collect payment directly from the patient. You will need to apply this modifier for every visit (i.e., each time you submit a claim).

I have a patient who is about to hit the $3,700 threshold, and I feel that continued treatment is medically necessary. What should I do?

If you believe treatment above the manual medical review threshold ($3,700) is medically necessary, then you will proceed in one of two ways, depending on whether you practice in a pre-review state or a post-review state. You can learn more here.

How do I know what services are medically necessary and/or covered?

There is no listing of services that are considered medically necessary, as the medical necessity of any service may vary from patient to patient. That said, to determine which services Medicare covers, you should consult Medicare’s National Coverage Determination and Local Coverage Determination files,

How do I define medical necessity?

To help therapists and payers better understand and apply the concept of medical necessity as it relates to therapy services, the APTA adopted the Defining Medically Necessary Physical Therapy Services position in 2011. According to this statement, “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.”

This description might not fall in line with every single “medically necessary” definition out there, but it does provide a better level of therapy-specific detail than most. It also seems to be on par with Medicare’s reimbursement requirements, especially considering the recent court decision that definitively eliminated patient improvement as a condition of payment. For more information, check out this resource.

I have a patient who has seen a different therapist for a different episode of care during the current benefit period. Would those services count toward the cap?

Yes. Each time a new Medicare patient comes to you for treatment, it’s crucial that you determine whether the patient has received any other therapy services during the current benefit period, as those services would apply to the cap. To calculate the patient’s “running total” toward the therapy cap, you can reference the allowable fee schedule. In the event that the patient can’t provide you with a history of the therapy services he or she has received, you can request this information from CMS by contacting your Medicare contractor. (Keep in mind that the amount that goes toward the limit reflects the date of claim receipt, not the date of service).

I continued billing for therapy services after a patient had exceeded the cap, and Medicare denied my claims. Why?

If it was appropriate to affix the KX modifier (i.e., the services were medically necessary) and you did not do so, Medicare may have denied the claim. Or, if the services were not medically necessary, then Medicare may have denied the claim simply because the patient had exhausted his or her benefits for the current benefit period.  

Once the patient has met the therapy cap, is it necessary to include specific language on our documentation to acknowledge that we’re aware we’re providing services beyond the cap?

If you continue treatment beyond the cap, you are doing so because you believe that treatment is medically necessary. Thus, your documentation must clearly support the medical necessity of continued treatment. There are no required phrases or verbiage you must use to demonstrate this; simply document as you normally would—with the understanding that your documentation will serve as justification that the services you are providing are medically necessary.

Should I issue an ABN—and affix modifier GA to corresponding claims—any time a patient has had prior PT treatment and I’m not sure how close he or she is to the cap?

No. Each time a new Medicare patient comes to you for treatment, it is crucial that you determine whether the patient has received any other therapy services during the current benefit period, as those services would apply to the cap. If you determine that a patient has exceeded the therapy cap and you believe that continuing treatment is medically necessary, you would affix the KX modifier in compliance with the automatic exceptions process. For more information on the therapy cap, check out this resource.

ABNs

What is an ABN?

An Advance Beneficiary Notice of Noncoverage (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. You can learn more about ABNs here.

How do I submit an ABN?

According to this document, “you do not need to submit a copy of the ABN [to Medicare], but you must have it available on request.”

Can’t I just issue an ABN to every patient who is about to exhaust his or her benefits (i.e., hit the therapy cap) for the year?

You can only issue an ABN to—and subsequently collect cash payment from—the patient if the services you are providing above the cap are no longer considered medically necessary. If the services are medically necessary, then you would affix the KX modifier to the claim and continue treating the patient. Check out this resource for more information on therapy cap exceptions.

Should patients who are about to hit the $3,700 threshold sign an ABN if continued therapy is medically necessary? What if it’s not medically necessary?

You should never issue an ABN for services you believe are medically necessary. If you believe therapy beyond the $3,700 threshold is medically necessary, you must go through the manual medical review process to continue treatment. At that point, one of two things will happen, depending on whether you practice in a pre-payment review state or a post-payment review state. (You should continue to attach the KX modifier to claims that exceed the $3,700 threshold.) If, on the other hand, you believe treatment above the manual medical review threshold is not medically necessary—but the patient wishes to continue receiving treatment and is willing to pay out-of-pocket for it—then you can issue an ABN and begin treating the patient on a cash-pay basis.

What is the difference between a voluntary and involuntary ABN?

Required (i.e., involuntary) ABNs should be used when the therapist is providing Medicare-covered services that are not considered medically necessary for a particular patient/case. Voluntary ABNs, on the other hand, are considered optional. They can be issued when the therapist is providing services that Medicare never covers. For more information, refer to this FAQ.

Should I issue ABNs to Medicare patients in order to charge them for supplies (e.g., cold packs or therapy bands)?

Yes. According to this page, “Since few insurers reimburse the cost of home-based exercise products, it’s best to direct-bill patients for the cost of the products. This can easily be done by collecting cash payment for the product at the time of service. Medicare providers should have the patient complete a Notice of Exclusions from Medicare Benefits (NEMB) and an Advanced Beneficiary Notice (ABN) to bill patients for non-covered services.”

Should I issue ABNs to Medicare patients in order to charge them for wellness services?

If you are providing non-covered services (like wellness services), then you are not required to issue an ABN. However, you may issue one on a voluntary basis, as explained in this FAQ.

Many SNFs require that patients sign ABNs when they first arrive to the facility—prior to receiving any treatment. They do this as a “just-in-case” precaution. Is this appropriate?

While the guidelines we discussed during the webinar apply specifically to Part B billing, it is our understanding that Medicare strongly advises against issuing “blanket” ABNs—regardless of the setting.

If I issue an ABN to a patient who is about to hit the cap because I have determined that continued treatment is not medically necessary, can I bill the patient’s secondary insurance if he or she requests that I do so?

Yes. As explained here, when you issue an ABN—and use the GA modifier on the claim that you send to Medicare—you are then allowed “to bill the patient or a secondary insurance if Medicare doesn’t cover services.”

Do I still have to continue billing Medicare after I’ve issued a required ABN?

Yes. Even after a patient has signed an ABN—thus agreeing to accept financial liability for the non-medically necessary or non-covered services you provide to him or her—you still must submit claims to Medicare using the GA or GX modifier (for more on ABN modifiers, refer to the Modifiers section below). Once Medicare denies the claim, you can collect payment from the patient or bill his or her secondary insurance.

Note: Submitting claims to Medicare—even though you expect Medicare to deny them—protects you and the patient. But, the patient can request that you not bill Medicare—and in that case, you must oblige. To understand ABNs from the patient’s perspective, check out this link.

How often do I have to issue an ABN?

Per Medicare, an ABN “can remain effective for up to one year.” However, if there is a change or addition to the type of care the patient is receiving, the therapist must issue a new ABN that accounts for that change.

What if—after I issue an ABN and collect payment from a patient—Medicare ends up paying the claim?

As explained in these instructions, “if Medicare or a secondary insurer subsequently pays all or part of the claim for items or services previously paid by the beneficiary to the notifier, the notifier must refund the beneficiary the proper amount in a timely manner.” (The therapy provider would be considered the “notifier.”)

What if the patient has not reached the cap, but he or she has achieved his or her goal and continued treatment is not medically necessary? Do I still need to issue an ABN if the patient wishes to continue receiving treatment?

Yes. For a detailed example of this scenario, refer to page 37 of this CMS document.

Modifiers

Does my billing software apply modifiers?

All relevant modifiers should be available for you to select within your billing software, and the software should then automatically add them to the electronic claim. If this functionality is not available in your current billing software, we recommend switching to a billing software that has it.

Can I use the GP modifier in the first placement and the KG modifier in the second position?

If you are providing physical therapy, you won’t receive payment without first attaching the GP modifier to the claim to indicate that physical therapy is being conducted. From there, KG codes could be used, although Medicare Administrative Contractors (MACs) are attempting to limit their use to reduce the number of overpayments made as a result of improper use throughout clinics.

Where can I learn more about G-codes and severity modifiers?

For more information on G-codes—and functional limitation severity modifier codes—check out this resource.

What about the KX modifier?

To receive reimbursement for medically necessary services that exceed the therapy cap, should I add the KX modifier to each line on the claim?

Yes, you should affix the KX modifier to each line of service that is medically necessary.

If I apply the KX modifier, should I also have a patient sign an ABN?

The KX modifier indicates that the therapy is medically necessary, so you would not use it if you have issued an ABN.

Is there a limit on the number of visits/claims for which I can use the KX modifier and continue to receive reimbursement from Medicare?

There’s no rule on the number of visits for which you can use the KX modifier. You can use the KX modifier as long as you believe therapy is medically necessary. However, when the patient hits the manual medical review threshold of $3,700, you’ll need to follow the processes outlined here.

Where on the claim form does the KX modifier go?

As shown in this example claim, the KX modifier goes in the Modifier section of every service line to which it applies.

What about ABN-related modifiers?

What are the ABN-related modifiers?

GA: Indicates that a required ABN is on file for a service or item not considered reasonable and medically necessary.

• Allows provider to bill the patient or a secondary insurance if Medicare doesn’t cover services.
• Ensures Medicare will automatically assign liability to the beneficiary upon denial.
• Medicare will use claim adjustment reason code 50 when denying lines due to the presence of the GA modifier (e.g., “These are noncovered services because this is not deemed a ‘medical necessity’ by the payer.”).

GX: Indicates a voluntary ABN was issued for non-covered services.

• Prompts automatic rejection from Medicare.
• Medicare systems will recognize and allow the GX modifier on claims, but will return the claim if the GX modifier is used on any line reporting covered charges.
• Can be combined with modifiers GY and TS (to indicate beneficiary liability) but not EY, GA, GL, GZ, KB, QL, or TQ.
  • TS = Follow-up service
  • EY = No doctor’s order on file
  • GL = Medically unnecessary upgrade provided instead of non-upgraded item; no charge and no ABN
  • KB = Beneficiary requested upgrade for ABN; more than four modifiers identified on claim
  • QL = Patient pronounced dead after ambulance is called
  • TQ = Basic life support transport by a volunteer ambulance provider

GY: Indicates a non-covered service.

• Used when an ABN is not on file; patient is inherently liable for charges because it’s a non-covered service.
• As of 2013, it is no longer appropriate to use the GY modifier to indicate non-medically necessary services that exceed the therapy cap. In that case, you need to apply the GA modifier to the claim. For more information, check out this resource.

GZ: Indicates that you expect the service to be denied because it isn’t medically necessary.

• Used when an ABN may be necessary but was not issued; patient is not responsible for payment.

For additional information about ABN-related modifiers as well as specific examples, please see this FAQ.

If I collect an ABN for a non-covered or non-medically necessary service, do I also need to affix a modifier to the claim?

If you have an ABN on file, you should include a GA or GX modifier on your claim so Medicare knows to deny the claim and assign financial responsibility to the patient. If you submit a claim to Medicare without acknowledging that you know the services are either not covered or not medically necessary, and Medicare denies the claim, you may not go to the patient for payment.

Why would I use a GX modifier?

The GX modifier indicates a voluntary ABN was issued for non-covered services. You would use this modifier to notify Medicare that you and your patient are aware that you’re providing a service that is not covered, and that Medicare should therefore deny the claim and transfer financial responsibility to the patient.

What’s the difference between GX and GZ?

GX indicates a voluntary ABN was issued for non-covered services, whereas GZ indicates that you expect the service to be denied because it isn’t medically necessary. You should use the latter when an ABN may be necessary but was not issued. In this case, the patient is not responsible for payment

Can I combine modifiers GA and GY together?

No, you should not use the GA and GY modifiers on the same claim, because they indicate two different things. For more information, check out this blog post.

I’ve used the GA modifier and Medicare continued to pay. Why is this?

The GA modifier should trigger Medicare to deny the claim. Please reach out to your MAC directly to see what the issue is.

Can I use a modifier—such as GY or GX—for telehealth services?

This is a tricky one. As explained here, even though Medicare does cover certain telehealth services delivered by eligible providers, “physical therapists are not listed as eligible providers of telehealth services through Medicare.” So, because Medicare doesn’t cover those services, you may be able to provide them on a cash-pay basis (and thus, use one of the modifiers mentioned above). However, it’s important to note that, as explained in the same article, not every state has added telehealth services to its PT scope of practice. Furthermore, “There are no defined rules for advancing licensure standards for physical therapists utilizing telehealth services on a large scale nationally.” Thus, it is imperative that you review your state’s practice act before providing telehealth services to any patient.

What about modifier 59?

When should I use modifier 59?

The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together and labeled these “edit pairs.” If you bill a CPT code that is linked to one of these pairs, you’ll receive payment for only one of the codes. However, if you’re providing these services wholly separate and distinct from one another, you can attach modifier 59 to indicate that you should receive payment for both.

When I use modifier 59, should I state in my documentation that the treatments were wholly separate and independent of one another?

Yes, your documentation should clearly communicate that the services were provided separately and independently.

Should I use modifier 59 every time I bill for two or more direct timed treatment procedures?

No, modifier 59 should only be applied to CCI edit pairs. For a list of CCI edit pairs, please refer to this post.

To which code in an edit pair should I affix modifier 59?

The CCI edit pair table indicates the code to which modifier 59 should be applied.

Are NCCI edit pairs available for the new evaluation codes?

Hopefully, that will be addressed in the physician fee schedule final rule, which we expect to see later this fall.

I’m receiving denials when billing CPT codes 97110, 97530, and 97140. What should I do?

This may be because 97140 and 97530 form a CCI edit pair. Thus, to receive reimbursement for both services, you’ll need to affix modifier 59 to 97530. For more information on linked services—including a chart of the most common therapy-related CCI edit pairs—check out this blog post.

What about the new modifiers meant to replace modifier 59?

CMS created new modifiers for providers to use in place of modifier 59 when appropriate. As this PT in Motion article explains, “The new modifiers—XE, XP, XS, and XU—are intended to bypass a CCI edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service.” However, even though these modifiers went into effect January 1, 2015, the APTA has stated that therapists do not need to start using them in place of modifier 59—at least not yet.

Can I provide—and bill for—a therapy intervention on the same date of service that I provide an evaluation?

That depends. In some cases, even if the evaluation code (97001) forms an edit pair with an intervention code, you can affix modifier 59 and get paid for both codes (if the manner in which you provided the services meets the proper criteria). In other cases, you cannot use modifier 59—which means you cannot bill for both the evaluation and the intervention. To see which services linked to 97001 are eligible for modifier 59, review the chart included in this blog post.

If a PT and OT are working together to treat a patient, and each of them provides a service that together form an edit pair, would modifier 59 be appropriate?

Medicare Part B has specific rules regarding co-treatment. 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. The OT or PT would then bill the timed treatment codes for the occupational or physical therapy. Additionally, documentation must clearly indicate the rationale for co-treatment and specify the goals each therapist will address through this method of intervention. Each therapist should document co-treatment sessions as such, specifically detailing which goals the team of therapists addressed and how the patient progresses. Lastly, therapists should limit therapy services performed during one treatment session to two disciplines.

As for modifier 59, here’s an example using the codes 97140 (manual therapy) and 97530 (therapeutic activities): when billing a 97140 and 97530 for the same session or date, modifier 59 is only appropriate if the therapist performs the two procedures in distinctly different 15-minute intervals. This means that you cannot report the two codes together if the two therapists performed them during the same 15-minute time interval. If your care meets that standard, you can add a modifier 59 to 97530 to indicate that it was a separate service and should therefore be payable in addition to the 97140.

How do I apply modifier 59 within WebPT?

To activate this feature within the application, please follow the steps below. Note that you’ll need to complete these steps for each insurance plan. We recommend applying this to commercial and government plans only (i.e., no workman’s compensation, legal/lien, and auto liability policies).

1. Select “Display Insurance,” located on the left side of the WebPT Dashboard.
2. Click “Edit” on the individual insurance for which you want to activate the feature.
3. Once the insurance editing screen opens, check “Apply CCI edits”; then, select “Save.”

Then, whenever you use two CPT codes that form an edit pair, the system will ask you whether you would like to apply modifier 59 (i.e., whether you have performed these services separately and distinctly from one another).

If you’re not yet a WebPT Member, you can see this functionality and an array of other awesome features in a free, live online demonstration. Request one here.

Supervision

Does Medicare require a PT to provide direct supervision of a PTA?

This may depend on your state practice act, but typically, PTAs must be supervised by licensed physical therapists specifically. For more information on Medicare’s supervision rules for PT assistants, techs, and students, check out this blog post.

Will Medicare pay for “maintenance care” provided by therapist assistants (e.g., PTAs and COTAs)?

Medicare will not pay for any services—including those provided as part of a maintenance program—that a care provider with a lower level of experience and/or education (e.g., a technician, caregiver, fitness instructor, or massage therapist) can provide. For more information, click the “What was the ruling on the Medicare Improvement Standard” button in the table of contents on this page. That said, Medicare does cover medically necessary maintenance care, which could be provided by a properly supervised PTA—as long as it falls into his or her scope of practice.

What are the direct supervision requirements for hospital-based outpatient rehabilitation?

According to this CMS resource, any physician or nonphysician practitioner must be immediately available to furnish assistance and direction throughout the procedure. The physician is not required to be present in the room where the procedure is performed or within any other physical boundary as long as he or she is immediately available.

Also, according to this resource, “for services not furnished directly by a physician or nonphysician practitioner, CMS would expect that these hospital bylaws and policies would ensure that the therapeutic services are being supervised in a manner commensurate with their complexity, including personal supervision where appropriate.” Thus, we recommend referring to your hospital administrators for further guidance.

Do all insurance companies adhere to Medicare’s supervision regulations?

In some cases, state practice act supervision requirements may actually be more stringent than Medicare’s. If that’s the case for you, the APTA says you should follow the rules of your state practice act.

Can a PTA ever discharge a patient?

According to the APTA, physical therapist assistants must work under the direction—and, at minimum, general supervision—of the licensed physical therapist. In other words, a PTA could work in concert with a supervising PT to discharge a patient, but the assistant could not perform this action alone.

Can home health or home-based outpatient therapy providers bill for treatment provided by a PTA or COTA?

Regarding PTA services provided under an outpatient plan of care, therapist assistants must work under the direct supervision of a licensed therapist. Generally, direct supervision means that the supervising therapist is present in the treatment location—but not necessarily in the same room—and available to intervene if necessary at the time the assistant performs the services. As for services provided under a home health plan of care, according to this resource, “Medicare guidelines regarding PT supervision of PTAs in home health state that a monthly supervisory visit is required. The practical application of this requirement is to make the visit no less than every 30 days. This is generally followed as the standard in the industry; some individual states may have practice acts that require more frequent supervision. Be sure to check your state guidelines if you are not sure of your particular state’s requirement.”

Prescription and Certification

Can a physician or NPP certify a POC verbally?

When a physician or NPP certifies a plan of care, he or she must sign and date it. Stamped signatures are not allowed (though electronic signatures are), and if the physician or NPP gives verbal certification, he or she must provide a signature within 14 days of that verbal notice.

How long do I have to obtain POC certification?

You must obtain certification within 30 calendar days of establishing the patient’s therapy plan of care.

What if the physician won’t sign and return the POC within 30 days?

This is where your relationships with physicians come in handy. Remember, the certifying provider doesn’t necessarily have to be the patient’s regular physician. Now, keep in mind that if the physician does not sign off, and you continue to treat the patient, you’re putting your reimbursements on the line. You’re also putting yourself at risk for triggering an audit if you’ve submitted a large volume of claims without the correct—and necessary—documentation.

Do we need to include referring provider information on the claim form? Medicare denied our claims due to invalid referring provider name and primary identifier.

Medicare will not pay for PT services unless the claim and documentation prove that a licensed physician has authorized the plan of care. On the claim form, there is a space for the NPI of the ordering/referring physician. If that NPI is missing, Medicare will deny the claim.

Can a chiropractor be the certifying physician?

No, there are exceptions to Medicare’s definition of “physician” with therapy plan of care certifications, specifically. As explained on page 9 of this resource, “Physician, with respect to outpatient rehabilitation therapy services, means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only). Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.”

I was told that I must obtain a physician referral before I can see a Medicare patient. Is that not the case?

Not anymore. Some level of direct access now exists in all 50 states, meaning you can—at minimum—provide an evaluation without obtaining a physician referral. However, regardless of the degree of direct access available in your state, you must obtain a physician signature (i.e., have the plan of care certified) within 30 days of beginning treatment. Curious about the direct access laws in your state? Check out our four-part series.

Do I need to obtain POC certification every time I develop a plan of care?

Yes. If you do not obtain certification within 30 calendar days of establishing the POC, you risk having your claims denied.

How often must I obtain POC recertification?

If the plan of care changes for any reason, it’ll need to be re-certified. Otherwise, Medicare requires recertification 90 days after the patient began receiving treatment.

Is the treatment of Medicare patients without a signed plan of care (say it has been 30 days and the POC has not yet been signed) considered “illegal,” or could I legally provide them and just not bill Medicare?

There is a lot of regulation around providing services to Medicare patients on a free or discounted basis, and doing so could potentially land your practice in hot water. Thus, we’d suggest either consulting with a healthcare law expert before doing so, or refraining from this practice entirely. Also, remember that Medicare will not pay for physical therapy services unless the claim and documentation prove that a licensed physician has authorized the plan of care. Full authorization must include the physician’s full name, location, and phone number as well as a doctor’s order that explains the diagnosis and level of treatment intensity.

Cash-Pay Rules and Regulations

Under what circumstances can I provide services to a Medicare patient on a cash-pay basis?

Your ability to collect cash from any Medicare patient is dependant on a variety of factors. Before you provide services to a Medicare beneficiary on a self-pay basis, you’ll need to answer several questions, including:

• Has the patient reached the cap?
• Is your treatment medically necessary?
• Is your treatment covered by Medicare?
• Is the patient willing to accept financial liability if the services you provide are not medically necessary?

For more on the nuances of Medicare and cash-pay, check out this blog series.

If I’m a non-participating provider, how can I submit claims to Medicare?

To be a “non-participating” provider, you still must enroll with Medicare, which means you should still be able to submit claims. You can learn more about what it means to enroll with Medicare as a non-participating provider here.

What’s the difference between “non-medically necessary” services and “non-covered” services?

Non-covered services are those that Medicare never, under any circumstances, covers (wellness services, for example). Non-medically necessary services, on the other hand, are covered services for which Medicare will not provide reimbursement because they do not meet the definition of medical necessity for a particular patient. To learn more about these two types of services, refer to this blog post. For a more detailed discussion on medical necessity, check out this blog post. To determine whether Medicare covers a particular service (e.g., iontophoresis), contact your local MAC.

If a service isn’t covered by Medicare, can I still provide that service to a Medicare patient?

Yes. You can provide services that are not covered by Medicare on a cash-pay basis, as explained in this blog post.

How do I determine how much to charge a Medicare patient for a non-covered service?

As far as we know, non-covered services would not be listed in the physician fee schedule. You’ll need to identity fair market value to determine appropriate pricing.

How much can I charge a Medicare patient for a covered—but non-medically necessary—service?

As Dr. Jarod Carter explains here, “you should not drop the pricing too far below the Medicare fee schedule. If you do price your maintenance services below the fee schedule, it is probably best if these discounts are given as ‘same-day payment discounts.’”

Can I accept cash from Medicare patients after they hit the therapy cap?

Participating providers may accept cash for services that exceed the cap if those services are not medically necessary. In such cases, you would issue an ABN and attach the GA modifier to the claim.

If a patient states that he or she wants to preserve his or her Medicare dollars, am I allowed to accept cash payment from the patient?

If a patient has Medicare, you are legally required to bill Medicare for all covered services. Per Section 40 of Chapter 15 of the Medicare Benefit Policy Manual, “The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare.”

I thought Medicare had to cover wellness and prevention services under the Affordable Care Act. Is that not the case?

Under the Affordable Care Act, Medicare will cover some wellness and prevention services. However, for these services to be covered, they must be provided during once-annual visits to a primary care physician. So, unless you’re working as a member of a physician’s established wellness program, it’s unlikely that your wellness services will overlap with what Medicare covers.

Re-Evaluations

When is it appropriate to perform a re-evaluation?

A re-evaluation is totally different from a progress note. Thus, therapists should never bill for a re-evaluation in place of a routine progress note. If you do perform—and bill for—a re-eval, you are essentially saying that some kind of significant change has taken place regarding the patient’s progress and, therefore, his or her plan of care (POC). More specifically, you should only bill for a re-evaluation if one of the following situations applies:

• Through your own clinical assessment, you note a significant improvement, decline, or change in the patient’s condition or functional status that was not anticipated in the POC for that interval.
• You uncover new clinical findings during the course of treatment that are somewhat related to the original treating condition.
• The patient fails to respond to the treatment outlined in the current POC, and you determine that a change to the POC is necessary.
• You treat a patient with a chronic condition and you don’t see him or her for treatment very often.
• Your state practice act requires re-evaluations at specific time intervals.
• The patient presents with a new diagnosis.

On the patient’s tenth visit, would it be appropriate to perform a re-evaluation and bill no charge?

In this situation, you would complete a progress note unless the patient requires a re-evaluation. Unsure of whether a re-evaluation is appropriate? Take a look at this blog post.

If I cannot bill a re-evaluation code when I complete a progress note, then how do I get paid for the time I spent completing the progress note?

Medicare does not reimburse for the time you spend documenting. To receive reimbursement for any service, it must apply to a billable CPT code. Confused as to what constitutes billable time? Head to this blog post.

Can I bill for a re-evaluation and therapy treatment on the same date of service?

If you perform a re-evaluation and certain services on the same day—and you provided those services wholly separate and distinct of one another—you may need to use modifier 59. To see if your codes form a CCI edit pair and therefore qualify for the use of this modifier, refer to this blog post.

Do I need to wait a certain period of time after providing an evaluation before I provide a re-evaluation?

Medicare does not require a certain length of time between evaluations and re-evaluations. However, your state practice act might. For more information on when it’s appropriate to perform a re-eval, please see this blog post.

I was told to bill for a re-evaluation at discharge. Is this correct?

No, a re-evaluation is only appropriate if specific conditions are met. To learn more about when it’s appropriate to bill for a re-eval, check out this blog post.

Everything Else

Are there any common billing patterns that are likely to trigger an audit?

Misusing modifier KX or 59; issuing blanket ABNs; and billing for an unusually high number of re-evaluations may increase your risk of a Medicare audit.

What is a MAC?

A MAC is a Medicare Administrative Contractor. MACs handle a plethora of compliance-related tasks, including probe audits, or prepayment review of claims that target “either particular services or particular specialties.” MACs also serve as resources for billing and compliance-related questions. To learn more about MACs, check out this blog post.

My practice is not considered a HIPAA-covered entity if we only submit paper claims—even if our hard drive is backed up online and we use eFax to send POCs to physicians—right?

All healthcare providers are HIPAA-covered entities, which means they must comply with certain rules governing the way they collect, share, and use protected health information. To learn more about HIPAA, refer to this resource.

Should I report the ICD-10 codes for the medical diagnosis on the referral, or should I report the codes for the signs/symptoms that I, as the therapist, am treating?

You can submit codes for both the medical diagnosis and the treatment diagnosis. However, remember that the treatment diagnosis code(s) must adequately support the medical necessity of your treatment, which means they should describe the patient’s condition as completely, specifically, and accurately as possible. For more information on coding for medical necessity, check out this blog post.

What is an appropriate long-term goal (LTG)? Can it be something as general as “maximize independence with functional mobility?”

For functional limitation reporting purposes, LTGs must contain measurable criteria. Thus, the example in the question would need to include a timeframe for achievement. For more advice on creating proper long- and short-term goals, check out this resource.

Do I complete a progress note every 30 days or every tenth visit?

As of January 1, 2013, the progress report for Medicare patients is required “on or before the 10th visit over the course of therapy.” The “30 days or whichever is sooner” requirement is no longer in place. Learn more here.

Do Medicare regulations apply to Medicare Advantage or Medicare replacement plans?

It depends. These are technically commercial insurances, so many Medicare programs and regulations—including PQRS and functional limitation reporting—do not apply. However, such plans do adhere to some Medicare guidelines, including the 8-Minute Rule.

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