- Outpatient Occupational and Physical Therapy Services Billing Guide
- Introduction to Outpatient OT and PT Services
- Outpatient Occupational and Physical Therapy Coverage
- Caregiver Training Services
- KX Modifier Threshold
- 2024 Annual Update to the Therapy Code List: Remote Therapeutic Monitoring
- Annual Update to the Therapy Code List
- Targeted Medical Review
- Functional Reporting - Using the G Codes
- What is the Advance Beneficiary Notice of Noncoverage and When to Use It in Outpatient Therapy
- Maintenance Programs
- Multiple Procedure Payment Reduction
- The National Correct Coding Initiative
- Comprehensive Error Rate Testing Program
- Recovery Auditor
- Common Billing Errors and Remittance Message
- Medical Review Therapy Documentation Checklist for Additional Development Request Letters
- Common Questions and Answers
- Related Content
- Related Articles
Outpatient OT and PT Services Billing Guide
Common Questions and Answers
- Can a PTA treat a Medicare B patient in an outpatient setting with direct supervision by the physical therapist?
Answer: Yes, however PTAs are limited in the services they may provide. Please see CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220. This section states, “PTAs may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage or furnish skilled maintenance program services; or take responsibility for the service. They act at the direction and under the supervision of the treating physical therapist and in accordance with state laws.
- Do I give the patient an ABN when they are approaching their cap?
Answer: You would only give the patient an ABN when you feel the continuation of services may be rejected by Medicare for medical necessity. If the patient is approaching the cap, but services will continue to be medically necessary for them you are to affix the KX modifier to the claim and document the medical necessity for continued services in their medical record.
- Can a physician script be used as the certification or recertification for the plan of care or does it have to be a signature on the plan of care itself?
Answer: A physician script can be used for the plan of care as long as it contains all the components for the plan of care. Please be sure to reference the information in CMS IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220.1.2 for guidelines on establishing the plan of care.
The payment is based off the certification by a physician or NPP of the plan of care developed by the therapist. They must sign and date your plan of care within 30 days of the implementation of the plan.
Medicare no longer requires a physician script/referral for physical therapy services. The patient can simply come to you directly for services. There however, may be a state requirement for the script, for which you will need to check with your own state. Also, some facilities may require a physician script.
- How long is the plan of care good for?
Answer: The plan of care is good for as long as what you have written in to it, up to 90 days. For example, if your plan of care indicates treatment will be a total of 45 days, then it is only good for 45 days.
- What do I do if the physician hasn’t certified the plan of care, after several attempts?
Answer: The payment for the claim is dependent on the certification of the plan of care. We realize you are at the mercy of the physician or NPP when it comes to this. You must make a concerted effort to obtain this for your records. Indicate in the patient’s medical record what times and dates you tried to receive this information from the provider. Also indicate whether it was a telephone call, fax, or mailed inquiry.
In the event you are asked for medical records and you still do not have the certification to the plan of care, the claim will get denied. Once you have obtained the certification you may appeal the claim for payment.
- How do I report the G-coding for the discharge if a patient just stops coming to therapy?
Answer: If you haven’t yet billed for the last service you may include the G-coding for the discharge on this claim. However, most of the time you have already billed out the visit and since the G-coding requires a billable service there isn’t much you can do. You will need to make an entry on the patients’ medical record that they self-discharged. CMS has issued specific instructions for the scenario when a patient returns to treatment within 60 days for the same functional limitation, or a different functional limitation.
See CMS’ Therapy Services web page for additional information. Note: Functional G-coding only applies to dates of service prior to 1/1/2019. - How do I report an evaluation procedure while I am reporting on a current functional limitation?
Answer: Report the evaluation as a one-time visit, utilizing all three codes of the G set. You may continue to report on the existing functional limitation while reporting all three codes for the evaluation at the same time.
Note: Functional G-coding only applies to dates of service prior to 1/1/2019.
Revised 11/2/2023