Medicaid Physical Therapy Billing Guidelines


How Payment Is Calculated On Tpl Claims

Medicare Guidelines for Billing Therapeutic Exercise 97110 PT, OT in 2020

When a member has coverage from both Montana Healthcare Programs and another insurance company, the other insurance company is often referred to as third party liability . In these cases, the other insurance is the primary payer , and Montana Healthcare Programs makes a payment as the secondary payer.

The Medical Review Threshold

Even when you use the KX modifier for services exceeding the therapy threshold, OT services or combined PT and SLP services exceeding $3,000 could receive a targeted CMS medical review. However, CMS will not review every eligible claim that exceeds the medical review threshold.

If your claim does get picked for targeted medical review, a third-party agency hired by CMS will analyze the claim in question. The claims inspector will verify that you provided appropriate services for the type and severity of your patients diagnosis at an appropriate duration and frequency. If documenting defensibly, your patients chart should be able to certify the patients level of complexity, severity, and that treatment beyond the threshold was necessary for the patients care.

If your practice has a high rate of claims errors on Medicare procedures, CMS may refer you to its Targeted Probe and Educate program. TPE gives you a chance to address issues with billing, but CMS may audit your practice if you dont successfully complete the program.

Documentation For Pta Reimbursement 2022

CMS first introduced payment modifiers in 2018 and asked rehab therapists to begin using them by 2020. Now, the actual payment differentials have taken effect on January 1, 2022. Modifiers should be applied on a per-code basis and should be included in the claim when billed. As a refresher, this means your claims should state something like:

  • Code XXXXX CQ/CO code applied: services fully provided by PTA/OTA, or
  • Code XXXXX CQ/CO code applied: PTA/OTA services provided 15%, or
  • Code XXXXX No CQ/CO code applied: PTA/OTA services provided less than 10%

If the services provided were only provided by the PT/OT then you would note: Code XXXXX CQ/CO NA

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How To Use Eekb

The eMedNY EEKB Search Tool web page allows providers to filter and search the EEKB by providing information to one of the three search methods:

  • “Search by eMedNY Edit”: using the five-digit “Edit Number” found on the paper/PDF remit
  • “Search by HIPAA Codes”: using the Claim Adjustment Reason Code/Remark Code found in 835 Remit or the Healthcare Claim Status Code/Entity Identifier Code found in the 277 claim status response or
  • “Search by Title Text”: using the text contained in the main title/header of the EEKB.
  • The eMedNY EEKB Search Tool web page can also be found by selecting the “eMedNY HIPAA Support tab” from the eMedNY home web page, then selecting the last option in the drop-down menu.

    Proposed Physical Therapy Billing Code Changes

    Understanding the Medicare 8
    • 989X1: Remote therapeutic monitoring initial set-up and patient education on use of equipment
    • 989X4: Remote therapeutic monitoring treatment management services, physician/other qualified health care professional team in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month first 20 minutes
    • 989X5: Each additional 20 minutes

    If you are a physical therapist , visit us here to see how Kareo can help you with your billing and EHR needs.

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    Can You Bill For Co

    If you bill under Medicare Part B, and there are multiple therapists, you cannot bill separately for services provided to the same client and at the same time.

    If you bill under Medicare Part A, therapists can bill separate treatment sessions as long as the therapists are from different disciplines and provide different treatments.

    Jimmo V Sebelius And The Maintenance Coverage Standard

    Lastly, providers should also be aware of the Jimmo settlement agreement made by CMS in 2013s Jimmo v. Sebelius decision. The case was centered on providing patients with routine maintenance of their condition, showcasing that medically necessary care does not necessarily mean a patient will show visible progress. Under this standard, your services are medically necessary as long as they slow the patients deterioration or help maintain function.

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    Medicares Past And Parts

    President Lyndon B. Johnson when he signed the Social Security Amendments of 1965. Medicare first provided health care coverage to Americans enrolled in cash assistance programs. In 1972, the program expanded to cover people ages 65 and older and those who have a disability or end-stage renal disease.

    Today, Medicare covers those over 65 years old, and people of all ages who have mental and physical disabilities, pregnant women, families with low income, and those who need long-term care. According to Medicares Enrollment Dashboard, about 64 million Americans received health coverage through the program in 2021.

    Medicare initially provided medical and hospital coverage. Today, Medicare insurance also covers prescription drugs, home health, and hospice, including treatments that fall under the rehab therapy umbrella. The Centers for Medicare and Medicaid Services manage the components of Medicare: Part A , Part B , Part C , Part D , and Medigap, an optional policy that helps with out-of-pocket Medicare costs.

    The Therapy Threshold Or Kx Modifier Threshold

    Medicare Documentation Requirements for PT OT SLP

    While Medicare Part B does cover a range of rehab therapy services, patients are subject to a therapy threshold. Providers can provide services that exceed the threshold if they certify the medical necessity of that care using the KX modifier when billing for reimbursement.

    CMS adjusts the threshold annually, and the KX modifier threshold will increase from $2,110 in 2021 to $2,150 as of January 1, 2022. Without the KX modifier in place, CMS will likely deny any rehab services that surpass the threshold. Luckily, some EMR systems, including the Insight Platform, can automatically track the threshold for each Medicare patient and can notify therapists and billers when a patient is near the max or may require the modifier.

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    Are Ptas Being Phased Out In 2022

    While PTAs arent being phased out, recent changes to the physical therapy fee schedule created a 6% cut in payments for physical therapy services with an additional 15% deduction from therapy assistant services. Combined, PTAs can expect to be paid 21% less in 2022 than they were in 2020.

    So, though PTA Medicare cuts are not an effort to phase out assistants, providers should anticipate that services furnished by a PTA will induce pay cuts in 2022. Changes to physical therapy assistant reimbursement will mean different things for each practice, but in general, providers may want to reconsider how patient services are allocated to their staff.

    Reminder: Sign Up For Emedny Training Webinars

    eMedNY offers several online training webinars to providers and their billing staff, which can be accessed via computer and telephone.

    Valuable provider webinars offered include:

    • ePACES for:
    • Medicaid Eligibility Verification System
    • New Provider / New Biller

    Webinar registration is fast and easy. To register and view the list of topics, descriptions and available session dates, providers should visit the eMedNY Provider Training web page. Providers are reminded to review the webinar descriptions carefully to identify the webinar appropriate for their specific training needs.

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    What Is The Difference Between Medicare And Medicaid

    Medicare is a federal health insurance program for individuals age 65 and older and those of all ages who have qualifying disabilities. People who qualify because of age or health conditions can receive benefits at any income level. Medicaid, which is administered through both federal and state governments, provides health coverage to low-income individuals.

    If you decide to treat Medicare patients, you must follow Medicare guidelines for reimbursement. If you also accept Medicaid at your practice, both the federal and state Medicare rules for outpatient physical therapy and state Medicaid rules apply. For example, not every state provides reimbursement for PT, OT, or SLP services through Medicaid.

    Some people qualify for both Medicare and Medicaid, which can further complicate the billing process. You might find the two programs have conflicting views about billing for a particular service. In this case, you must follow the stricter guidelines, which can mean a lower level of reimbursement. For example, if your state Medicaid program doesnt cover PT services that Medicare has deemed medically necessary , your patient may have to pay out of pocket.

    Physician Referrals And Medicare Plan Of Care

    Understanding the Medicare 8

    Medicare requires a plan of care that is written and initiated by the therapist and certified by a physician or non-physician practitioner. Oftentimes, Medicare patients are referred by a primary physician to a rehabilitative therapist, but physician referrals are not always a requirement for seeking care.

    In general, Medicare outpatient rehabilitation providers agree to provide and document the following elements of patient care in their Plan of Care:

    • Diagnosis, dysfunction, or impairment, including both objective and subjective notes from the provider and patient.
    • Assessment of the patients desired outcomes and potential for rehabilitation.
    • A comprehensive plan of care that includes:
    • The time frame of care
    • Interventions and services provided
    • Long-term goals for the patient
    • Frequency and duration of treatment sessions
  • Notes for each treatment session, including whether the patient kept the appointment, the services or interventions provided, the length of time of the session, and observations.
  • Progress reports at least every tenth visit that includes:
  • Evaluation of patients progress toward treatment objectives
  • Judgment about whether continued treatment will help the patients condition improve
  • Notes about changing provided therapies, if applicable
  • Indication for terminating services, if applicable
  • Discharge notes that follow the format of a progress report while documenting the final outcomes of treatment.
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    Rehabilitation Services Provided In A Long

    Long-term care facilities may provide rehabilitation services to both residents and members of the community, using either therapists the LTC employs or those they contract with through an outside vendor, such as a rehab agency or a therapist in private practice.

  • Therapists must provide services on the LTC premises
  • Rehabilitation services included in the LTC per diem rate may not be billed as an outpatient service
  • LTC facilities located in Minnesota no longer include rehabilitation services in their per diem
  • Bill services provided to members who are also eligible for Medicare following Medicares requirements
  • The LTC facility must bill for services provided by its employees
  • Either the vendor or the LTC facility may bill for services provided by contracted outside vendors however, the provider billing for and receiving payment for services is responsible for the accuracy of the claims and for maintaining patient records that fully disclose the extent of the benefits provided
  • The pay-to providers NPI and the rendering or treating providers NPI must be the same on the claim do not enter the therapists NPI as the rendering or treating provider when billing for services provided in a nursing home
  • A Providers Golden Rule: Medical Necessity And Defensible Documentation

    Besides credentialing, another aspect of Medicare compliance that providers will need to maintain is accurate chart notes that defensibly document their medically necessary care for Medicare patients. Medical necessity is required to receive reimbursement for rehab therapy services from Medicare. Your claim must clearly show that the treatments you provided meet the currently accepted medical standards for the patients condition.

    To fulfill the medical necessity standard, always strive to submit defensible documentation. In other words, your documentation should be able to legally prove medical necessity in the case of a Medicare audit. Your notes should illustrate the patients diagnosis, condition, and limitations and explain how the provided therapies address these issues. Detail the treatments you provided during the session and for how long. Include the care plan, measurable goals, and progress toward those goals, as well as subjective and objective observations .

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    Manual Organization And Maintenance

    This manual provides information specifically for physical, occupational, and speech therapy providers. Other essential information for providers is contained in the separate General Information for Providers manual. Providers are responsible for reviewing both manuals.

    A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. There is a list of contacts and websites on the Contact Us page of the Provider Information website. There is space on the inside of the front cover of this manual to record your NPI/API and CHIP/HMK numbers for quick reference when calling Provider Relations.

    Changes to manuals are provided through provider notices and replacement pages. When replacing a page in a manual, file the old pages and provider notices in the back of the manual for use with claims that originated under the old policy.

    Postural Restoration Form Of Physical Therapy

    Medicare Telehealth Coverage for Physical Therapists

    Postural restoration is a posture-based approach to physical therapy, which claims that it improves postural adaptations, the function of the respiratory system and asymmetrical patterns. Postural restoration supposedly re-position the musculo-skeletal system, correct movement imbalance, restore normal tonicity to muscles and strengthen efficient, balanced, functional activity. Physical therapists who administer postural restoration would initiate a process of rehabilitation that begins with re-positioning and re-positioning therapeutic activities are carefully constructed exercises to restore neutral alignment to the musculo-skeletal system. Once neutral alignment is attained, it must be maintained and integrated into the movement patterns individuals use in daily activities. A personalized exercise program is designed to improve strengthening from lying to sitting to standing and finally back into up-right movement in a more balanced way. In summary, postural restoration physical therapy create a more balanced / less stressed physical foundation for life activities, sports activities and for rehabilitation following trauma or surgery. Postural Restoration

    However, there is no published data on the clinical value of postural restoration form of physical therapy.

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    Kinesio Taping / Mcconnell Taping / Taping

    Kinesio taping is a method of taping utilizing a specialized type of tape. It differs from traditional white athletic tape in the sense that it is elastic and can be stretched to 140 % of its original length before being applied to the skin. It subsequently provides a constant pulling force to the skin over which it is applied unlike traditional white athletic tape. The fabric of this specialized tape is air permeable and water resistant and can be worn for repetitive days. Kinesio tape is being used immediately following injury and during the rehabilitation process. However, its effectiveness has yet to be established.

  • without taping
  • immediately after taping
  • 12 hours after taping with the tape remaining in situ.
  • therapeutic taping,
  • control taping, and
  • no taping.
  • The American College of Occupational and Environmental Medicine’s practice guidelines on “Evaluation and management of common health problems and functional recovery in workers” did not recommend taping or kinesiotaping for acute, subacute, or chronic LBP, radicular pain syndromes or other back-related conditions.

  • the experimental group received Kinesio taping to the cervical spine and
  • the placebo group received a sham Kinesio taping application .
  • with the ankle taped with non-elastic, white sports tape,
  • Kinesio tape, and
  • with no tape.
  • Current Procedural Terminology Codes

    As you may know, CPT codes are medical codes that describe the procedures and services you are performing to billing agencies and insurance companies. They were created by the American Medical Association in 1966 to simplify and standardize procedural reporting.

    Each code consists of five characters. There are three code categories:

  • Category 1 = services and procedures
  • Category 2= performance management
  • Category 3 = emerging and experimental services and procedures
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    Therapists Employed By Nursing Facilities Hospitals Or Home Health Agencies

    The billing instructions in this chapter apply to independent therapists who bill on professional or CMS-1500 claims. Independent therapists must be individually enrolled Montana Healthcare Programs providers to bill for services. Therapists who are employed by nursing facilities do not need to be individually enrolled in the Montana Healthcare Programs when there services are to be billed by the nursing facility directly to Montana Healthcare Programs. The nursing facility provider will be responsible for meeting the enrollment and billing requirements under the therapy provider number. Therapists that are employed by hospitals or home health agencies should refer to the corresponding provider manual for requirements and billing procedures, which may vary.

    What Do These Changes To The Physician Fee Schedule Mean

    Physical Therapy Billing Guidelines: Medical Billers and Coders

    When Congress passed the Bipartisan Budget Act in 2018, it directed CMS to establish a payment differential for services provided in whole or in part by physical therapist assistants and occupational therapist assistants. This payment rate is 85% of the rate physical therapists and occupational therapists are paid, as indicated by claims modifiers.

    However, the original legislation did not clarify what exactly in part meant. Exactly how much of the care was considered in part? Well, the 2022 ruling adheres to the de minimis standard established in the 2019 Fee Schedule, which defines in part as when the minutes of the portion that is provided by the assistant exceed 10% of the total minutes for that service or unit of service.

    The modifiers CQ for PTAs and CO for OTAs must be attached to services exceeding the 10% time threshold. These modifiers are to be included on the claim on the same lines where any GP or GO modifiers are provided. However, if a therapist and an assistant treat a patient together, meaning the assistant is the second pair of hands during treatment, then the modifier does not apply.

    The payment differential and use of the CQ and CO modifiers apply to all private practice, hospital outpatient departments, comprehensive outpatient rehabilitation facilities , skilled nursing facilities , home health agencies, and rehabilitation agencies. These modifiers, as well as updates to PTA reimbursement 2022, do not apply to Critical Access Hospitals.

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