Making Medicare Work for Physical, Occupational and Speech Therapists Workshop Q&As

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1 Making Medicare Work for Physical, Occupational and Speech Therapists Workshop Q&As This Question and Answer (Q&A) series was developed from the Making Medicare Work for Physical, Occupational and Speech Therapists Web-based training that was recently presented by the NAS Provider Outreach and Education department. Q1. Is the cap amount of $1,860 paid on the Medicare allowed or paid charges? A1. The annual limit is on the allowed amount for outpatient physical therapy and speech-language pathology combined of $1860; the limit for occupational therapy is $1860. Limits apply to outpatient Part B therapy services from all settings except outpatient hospital and hospital emergency room. As with any Medicare payment, beneficiaries pay the coinsurance (20 percent) and any deductible that may apply. Medicare will pay the remaining 80 percent of the limit after the deductible is met. Q2. Is an Advance Beneficiary Notice of Noncoverage (ABN) required to be signed if a patient is discharged from the therapy plan under outpatient Medicare B, because their goals have been met; however, the patient wishes to continue therapies? A2. In order for Medicare to pay for therapy, the patient must be under the care of a physician with a plan of care that meets the need of being administered by a skilled therapist. An ABN would be necessary if this requirement is no longer met. The modifier GA should be used if therapy cap limitation amount is still available and the modifier GY if they have met their annual limitation. Q3. How do you bill for time and code for splinting? A3. Splints should be coded using and with the appropriate modifier for the plan of care (GP for physical therapy and GO for occupational therapy). Q4. Can a Chiropractor order therapy services? A4. Chiropractors may not order for services at this time or certify/recertify plans of care for therapy services. Please reference Internet Only Manual (IOM) Medicare Benefit Policy Manual, Publication 100-2, Chapter 15, Section, Q5. Is there a time frame to do a re-evaluation? What is necessary for reimbursement?

2 A5. Re-evaluations are separately payable and are periodically indicated during an episode of care when the professional assessment of a clinician includes a significant improvement, or decline, or change in the patient's condition or functional status that was not anticipated in the plan of care. Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, re-evaluations must also meet Medicare coverage guidelines. Q6. Are electronic signatures sufficient for plan of care and progress notes? A6. Medicare requires that all services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable. Electronic signatures accompanied by a phrase similar to electronically signed by, reviewed by, etc and may include a date and time are the acceptable format. Q7. Are there any special rules for Physical Therapy Assistants (PTAs) when it comes to Medicare? A7. A Physical Therapist must supervise PTAs. The level and frequency of supervision differs by setting (and by state or local law). General supervision is required for PTAs in all settings except private practice (which requires direct supervision) unless state practice requirements are more stringent, in which case state or local requirements must be followed. The services of a PTA shall not be billed as services incident to a physician/npp s service, because they do not meet the qualifications of a therapist. Q8. Are therapy modifiers necessary on non-listed codes? A8. One example of a non-listed code is where a therapy modifier is indicated regarding the provision of services described in the CPT code series, through 29590, for the application of casts and strapping. Some of these codes previously appeared on the therapy code list, but were deleted because we determined that they represented services that are most often performed outside a therapy plan of care. However, when these services are provided by therapists or as an integral part of a therapy plan of care, the CPT code must be accompanied with the appropriate therapy modifier. Q9. Can a therapy assistant perform services on the days the therapist is not in the office? A9. Therapy assistants must perform services under direct supervision, which requires that the supervising private practice therapist be present in the office suite at the time the service is performed. These direct supervision

3 requirements apply only in the private practice setting and only for therapists and their assistants. In other outpatient settings, supervision rules differ. The services of support personnel must be included in the therapist s bill. The supporting personnel, including other therapists, must be W-2 or 1099 employees of the therapist in private practice or other qualified employer. Q10. Does Medicare allow a qualified Physical Therapist to provide services to Medicare beneficiaries with a temporary license? A10. A qualified Physical Therapist as defined in the IOM states that a qualified physical therapist (PT) is a person who is licensed, if applicable, as a PT by the state in which he or she is practicing unless licensure does not apply, has graduated from an accredited PT education program and passed a national examination approved by the state in which PT services are provided. The phrase, by the state in which practicing includes any authorization to practice provided by the same state in which the service is provided, including temporary licensure, regardless of the location of the entity billing the services. Q11. What services, if any, can a therapy student assist or perform on a Medicare patient? A11. Only the services of the therapist can be billed and paid under Medicare Part B. The services performed by a student are not reimbursed even if provided under line of sight supervision of the therapist; however, the presence of the student in the room does not make the service unbillable. Medicare pays for the direct (one-to-one) patient contact services of the physician or therapist provided to Part B patients. Group therapy services performed by a therapist or physician may be billed when a student is also present in the room. EXAMPLES: Therapists may bill and be paid for the provision of services in the following scenarios: The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment. The qualified practitioner is present in the room guiding the student in service delivery when the therapy student and the therapy assistant student are participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.

4 The qualified practitioner is responsible for the services and as such, signs all documentation. A student may, of course, also sign, but it is not necessary, since the Part B payment is for the clinician s service, not for the student s services. Q13. Can a skilled nursing home (SNF) patient come to our office to receive therapy services? A13. Medicare beneficiaries in a Part A stay of a SNF visit must receive all of their therapy services through the SNF either provided by the SNF themselves or through an arrangement. All therapy services must be billed out through the SNF on a UB-04. Independent therapy services billed out during a SNF Part A stay will be denied. Therapy services are part of the consolidated billing rules. Q14. Can the training of a caregiver be covered? A14. It can be covered if is performed along with the therapy session for the patient and is included as part of the treatment and is in the treatment plan. It should not be started after the patient has made their goal. Q15. Is the referral from a physician valid for 30 days, and the recertification at that time would be valid for an additional 90 day? A15. A referral is valid for 30 days however, a referral is not necessary to begin therapy. Medicare regulations state the patient must be under a physician s care and that the plan of care must be certified within 30 days by the overseeing physician to continue treatment. The re-certification must take place within 90 days. Q16. If an original evaluation is done, can a second evaluation also be performed on the same day? Should the number of units be billed as two? A16. Only one evaluation can be paid per day and the number of units should be one as these services are not timed codes. Q17. Does the use of the time codes need to indicate in the documentation the start and stop times of the each of the codes used in that daily session? A17. In the IOM Medicare Benefit Policy Manual, Publication , Chapter 15, Section 230.3B, titled Treatment Notes, indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be

5 documented specifically in the Treatment Note. However, the total number of timed minutes must be documented within the record for the day. This example indicates how to count the appropriate number of units for the total therapy minutes provided. Example: 24 minutes of neuromuscular reeducation, code 97112, 23 minutes of therapeutic exercise, code 97110, Total timed code treatment time was 47 minutes. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.

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