For Medicare recipients, coverage for occupational therapy as an outpatient is covered through Part B. Medicare recipients who have Original Medicare Part B have coverage for several types of outpatient therapy which include occupational therapy, physical therapy, and speech-language therapy.
Full Answer
Does Medicare reimburse for Part B physical and occupational therapy?
Medicare reimburses for Part B physical and occupational therapy services when the claim form and supporting documentation accurately report medically necessary covered services. Thus, developing legible and relevant documentation is only one piece of the reimbursement puzzle. Your documentation must also:
What are time-based CPT codes for Occupational Therapy Medical Billing?
Some occupational therapy medical billing CPT codes are “time-based” codes. Others are “untimed” codes. All procedures designated by time-based CPT codes are required to follow the Medicare CMS “8-Minute Rule.” The Centers for Medicare & Medicaid Services, or CMS, has released the following statement regarding billing units:
Does Medicare pay for outpatient therapy services?
This law included two provisions related to Medicare payment for outpatient therapy services including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services:
What is the CPT code for outpatient rehab therapy?
Group billing for outpatient rehab therapy (Part B) is substantially different than Part A group billing. The CPT code for group therapy—97150—denotes skilled treatment by the therapist that is not one-on-one.
Is CPT 97110 covered by Medicare?
Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code. CPT codes 97110, 97112, 97113, 97116, and 97530 describe several different types of therapeutic interventions.
Does Medicare cover code 99213?
Medicare will pay a physician for an AWV service and a medically necessary service, e.g. a mid-level established office visit, Current Procedural Terminology (CPT) code 99213, furnished during a single beneficiary encounter.
How Much Does Medicare pay for 97530?
Therapeutic activities (97530) sees a 2.45% decrease from its 2020 level of $40.42 to $39.43 in 2021.
Can 97116 and 97530 be billed together?
So for example, if PT provided gait training (97116) and OT provided therapeutic activity (97530), the billing claim would need Modifier 59 on the 97116 charge to allow for payment of both codes, otherwise, the NCCI edit would only allow payment for 1 code.
Does Medicare pay for 99214?
Medicare and other Insurance are pleased to pay the lesser money to providers if they (the doctors) are willing to under use the CPT code 99214....CPT CODE 2016 Fee 2017 FEE.99201$35.96 $43.699212$37.17 $43.199213$58.89 $72.799214$88.33 $107.299215$118.95 $144.85 more rows
Does Medicare pay for 99215?
The 99215 represents the highest level of care for established patients being seen in the office. Internists selected the 99215 level of care for only about 4.86% of established office patients in 2019. The Medicare allowable reimbursement for this level of care is $183.19 and it is worth 2.8 work RVUs.
How Much Does Medicare pay for 99214 in 2021?
$132.94By Christine Frey posted 12-09-2020 15:122021 Final Physician Fee Schedule (CMS-1734-F)Payment Rates for Medicare Physician Services - Evaluation and Management99213Office/outpatient visit est$93.5199214Office/outpatient visit est$132.9499215Office/outpatient visit est$185.9815 more rows•Dec 9, 2020
What does CPT code 97530 pay?
97530 CPT code may use to charge individual therapist or therapy assistant services. It is illegal for the same therapist or therapist's assistant to administer identical or different treatments to the same patient simultaneously to avoid double billing (s).
How Much Does Medicare pay for 90837?
$132.69What is the difference between the “facility rate” and “nonfacility rate” for telehealth services?CodeService2021 Facility Rate90832Psychotherapy 30-minutes$68.7490837Psychotherapy 60-minutes$132.6996132Neuropsych Test Eval$106.0896158Hlth Bhvr Intrv Indvl$58.971 more row•Dec 10, 2021
Can 97530 and 97140 be billed together?
Hello, 97140 & 97530 may not be billed together due to they are Mutually exclusive, however a modifier is allowed.
What modifier should be used with 97530?
59 modifier/Yes, you are permitted to bill 97530 with 97164 if you use the 59 modifier/X modifier. If you do not bill with the appropriate modifier, then 97164 (Column Two code) will be denied.
Can 97166 and 97530 be billed together?
Just like that, PT/OT Evaluations (97161, 97162, 97163, 97165, 97166, 97167) and Therapeutic Activities (97530) could not be billed together on the same day, for the same patient, across all disciplines with the same provider.
How long can a therapist bill for a supervised modality?
In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 - 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.
How often is 97150 billed?
In private practice settings for physical and occupational therapists and in physician offices where therapy services are provided incident to the physician, Medicare expects the group therapy code (97150) to be billed only once each day per patient. In the facility/institutional therapy settings, the group therapy code could be applied more than once. However, the occasional situation where group therapy is billed more than once each day would require sufficient documentation to support its medical necessity and clinical appropriateness of providing more than one separate session of group therapy.
Can a therapist bill a patient separately?
Therapists, or therapy assistants, working together as a "team" to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.
note
Medicare law no longer limits how much it pays for your medically necessary outpatient therapy services in one calendar year.
note
To find out how much your test, item, or service will cost, talk to your doctor or health care provider. The specific amount you’ll owe may depend on several things, like:
note
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
Refer to Local Coverage Determination (LCD) L35036, Therapy and Rehabilitation Services (PT, OT), for reasonable and necessary requirements and frequency limitations. The Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) code (s) may be subject to National Correct Coding Initiative (NCCI) edits.
ICD-10-CM Codes that Support Medical Necessity
It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted.
ICD-10-CM Codes that DO NOT Support Medical Necessity
All those not listed under the "ICD-10 Codes that Support Medical Necessity" section.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
CMS National Coverage Policy
Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy.
Article Guidance
This article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Outpatient Physical and Occupational Therapy Services L34049.
ICD-10-CM Codes that DO NOT Support Medical Necessity
The following ICD-10-CM Codes do not support the medical necessity for the CPT/HCPCS code 97035.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
Spotlight
The Therapy Services webpage is being updated, in a new section on the landing page called “Implementation of the Bipartisan Budget Act of 2018”, to: (a) Reflect the KX modifier threshold amounts for CY 2021, (b) Add more information about implementing Section 53107 of the BBA of 2018, and (c) Note that the Beneficiary Fact Sheet has been updated.
Implementation of the Bipartisan Budget Act of 2018
This section was last revised in March 2021 to reflect the CY 2021 KX modifier thresholds. On February 9, 2018, the Bipartisan Budget Act of 2018 (BBA of 2018) (Public Law 115-123) was signed into law.
Other
On August 16, 2018, CMS issued a new Advance Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ) document to reflect the changes of the Bipartisan Budget Act of 2018. Please find the document in the below Downloads section titled: “August 2018 ABN FAQs”.
What is Medicare Part B?
Medicare Part B—a.k.a. medical insurance —helps cover medically necessary and/or preventive outpatient services, including lab tests; surgeries; doctor visits; and physical, occupational, and speech therapy treatment. As with Part A, individuals become eligible to receive Medicare Part B insurance at age 65—or younger in cases of disability and end-stage renal failure. Unlike Part A, though, most beneficiaries pay a monthly premium (starting at $135.50 in 2019) for Part B. Then, once a patient meets his or her deductible ($185 this year), he or she will “typically pay 20% of the Medicare-approved amount for most doctor services…outpatient therapy, and durable medical equipment (DME).” So far, so good, right? Now let’s get into the tricky stuff:
What is the CPT code for group therapy?
The CPT code for group therapy—97150 —denotes skilled treatment by the therapist that is not one-on-one. When billing for group therapy under Part B—unlike Part A—the patients in the group do not require the same or similar diagnoses and they do not need to be doing the same or similar activities.
What is Part B in home health?
Beyond the first 100 days, Part B covers the payments. Additionally, home health therapists can only bill outpatient (Part B) home health services if patients are not "not homebound or otherwise are not receiving services under a home health plan of care.".
Can a physical therapist be a Medicare beneficiary?
If you’re in private practice—and you accept Medicare beneficiaries as a physical therapist, occupational therapist, or speech therapist in private practice— then you provide services that fall under Medicare Part B. However, if in doubt, always refer to your Medicare contract. (As a note, Part B is billed under the practice and therapist NPIs.)
Does Medicare cover outpatient rehab?
If you’re an outpatient rehab therapist, it’s especially “important to note that Medicare does not cover Medicare Part B services for patients who are receiving Part A services. Thus, be sure to ask all patients about concurrent care.”.
Is CMS using the same definition for group therapy?
With encouragement from the APTA, CMS is now using the same definition for group therapy in both SNF and inpatient rehabilitation settings: “two to six patients doing the same or similar activities.” According to the APTA, that means CMS is no longer using the “rigid 4-person definition.” Furthermore, CMS “believes aligning the group therapy definition serves to improve the agency’s consistency in payment policies across PAC settings, and to create opportunities for site neutral payments.”
Is concurrent therapy allowed under Medicare Part B?
According to the resource, concurrent therapy is not allowable under Medicare Part B, but it is allowable under Medicare Part A as long as certain provisions are met, which are explained in the article. As for documenting in and out time, Medicare no longer requires this as of 2007.
What is CPT code?
Certain current procedural terminology (CPT) codes are set by the American Medical Association to designate services provided by occupational therapists. All occupational therapists must have a thorough understanding of the procedure codes needed to run their practice efficiently and bill properly for the services they provide.
What is occupational therapy?
Occupational therapy is a professional field that employs assessment and intervention to develop, recover, and maintain the functions of everyday human activities. Occupational therapy evaluations typically include an occupational profile, patient medical and therapy histories, relevant assessments, and the development of a plan ...
What is an occupational therapy evaluation of low complexity?
An occupational therapy evaluation of low complexity requires these components: An occupational profile and medical and therapy history, which includes a brief history comprising a review of medical and/or therapy records relating to the presenting problem.
What is a therapeutic procedure?
Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. 97112. Neuromuscular reeducation of movement, balance, coordination, kinesthetic. Sense, posture, and/or proprioception for sitting and/or standing activities.
Do modifiers have to be entered correctly?
Modifiers must be entered correctly on all claims . If they are not, the insurance companies will deny the service. Practice managers must ensure that the patient did not hit their cap for services provided.
Does Medicare have a cap on therapy?
Medicare has a usage cap with therapy services. As such, documentation must show that the beneficiary qualifies of the therapy services justify a cap exception. Documentation must further show that services are reasonable, necessary, and require the skills of a therapist.
Medicare Part B Reimbursements in Recent Decades
In the 1990s, the Office of Inspector General detected fraudulent activity at nursing homes in the form of excessive billing and charges for unused supplies. The Benefits Improvement and Protection Act of 2000 limited the consolidated billing requirement to Medicare services not covered by Part A.
How to Fill Out Medicare Part B Reimbursements Forms
Some seniors and disabled individuals are automatically enrolled in Medicare Part B, while others must sign up for it, which can either be done online or by mail .
Who Pays for Medicare Part B coverage?
Medicare Part B reimbursement occurs after the deductible has been met.
Summary
Medicare Part B pays for up to 80% of the costs of physical therapy, occupational therapy, and speech-language pathology in long term care facilities. However, it is up to the facility to document the services it provides. Further, it is up to elders to opt into Medicare Part B and submit their forms.
When did Medicare discontinue the Functional Limitation Reporting Program?
Medicare discontinued this program on January 1, 2019.
How long does it take for Medicare to recertify?
And even when things do go according to plan, Medicare requires recertification after 90 days of treatment. If you’re a WebPT Member, you can use WebPT’s Plan of Care Report to identify which plans of care are still pending certification as well as which ones require certification—before those 90 days are up.
What is a POC in therapy?
The Plan of Care (POC) Based on the assessment, the therapist then must create a POC —complete with treatment details, the estimated treatment time frame, and the anticipated results of treatment. At minimum, Medicare requires the POC to include: Medical diagnosis. Long-term functional goals.
How long does it take for Medicare to discharge a patient?
Medicare automatically discharges patients 60 days after the last visit. Unfortunately, if the patient has been discharged, then you will need to perform a new initial evaluation. If you do not live in a direct access state, then you will also need to to get the physician's signature on the patient's new POC.
What is the evaluation of a licensed therapist?
Before starting treatment, the licensed therapist must complete an initial evaluation of the patient, which includes: Objective observation (e.g., identified impairments and their severity or complexity) And, of course, all of this should be accounted for you in your documentation.
How long do you have to recertify a patient?
If this occurs, you'll need to obtain a recertification from the physician. And no matter what, you must obtain a recertification after 90 days. So, to answer your first question, no—there is no rule that you must send the patient back to the referring physician after 10 visits.
How often do you need a progress note for Medicare?
Currently, Medicare only requires a progress note be completed, at minimum, on every 10th visit. I hope that helps!