when filing physical therapy claims to medicare, what point of service should be used?

Do Medicare billing guidelines apply to physical therapy?

If a fair percentage of your clients have Medicare insurance, it’s important to understand Medicare billing guidelines for physical therapy and what you need to do in order to ensure that the highest possible number of claims are settled quickly and in full.

How do I bill Medicare for therapeutic exercise?

Sometimes that’s easy: if you provide 15 minutes of Therapeutic Exercise you bill 1 unit of that code, 30 minutes of Neuromuscular Re-education is 2 units of that code. However, this is where Medicare’s totaling of the time complicates things.

Can a cash PT complete and submit a claim to Medicare?

But a cash PT who has no relationship necessarily cannot “complete and submit a claim” to Medicare for the PT’s services, and thus payment cannot be “made under” the program.

Is the GP modifier still required for physical therapy?

Despite a proposed change to the therapy modifiers (GP, GO, and GN) in the 2019 proposed rule, CMS has decided to let them be. Thus, physical therapists must continue to affix the GP modifier to all claim lines for services performed under a physical therapy plan of care.

What is the difference between POS 22 and 11?

I think it would be POS 11 even if it is owned by the hospital it is offsite and in an office. 22 POS to me is when a service is performed in the hospital and the patient is never admitted.

What is the difference between POS 19 and 22?

Beginning January 1, 2016, POS code 22 was redefined as “On-Campus Outpatient Hospital” and a new POS code 19 was developed and defined as “Off-Campus Outpatient Hospital.” Effective January 1, 2016, POS 19 must be used on professional claims submitted for services furnished to patients registered as hospital ...

What is a place of service 22?

On Campus-Outpatient HospitalDatabase (updated September 2021)Place of Service Code(s)Place of Service Name22On Campus-Outpatient Hospital23Emergency Room – Hospital24Ambulatory Surgical Center25Birthing Center54 more rows

What is place of service 11 in medical billing?

physician office spacePhysicians shall use POS code 11 (office) when services are performed in a separately maintained physician office space in the hospital or on the hospital campus and that physician office space is not considered a provider-based department of the hospital.

Is POS 23 considered outpatient?

Using of POS 23 with modifier 26 * Hospital outpatient (place of service 22). * Emergency Room (place of service 23).

Is POS 23 a facility or non facility?

The list of settings where a physician's services are paid at the facility rate include: • Telehealth (POS 02); Outpatient Hospital-Off campus (POS code 19); • Inpatient Hospital (POS code 21); • Outpatient Hospital-On campus (POS code 22); • Emergency Room-Hospital (POS code 23);

What is the difference between POS 21 and 22?

However, for a service rendered to a patient who is an inpatient of a hospital (POS code 21) or an outpatient of a hospital (POS code 22), the facility rate is paid, regardless of where the face-to-face encounter with the beneficiary occurred.”

What is the difference between POS 02 and POS 10?

POS 02 has been changed to reflect patients who receive telehealth in locations other than their home, and POS 10 has been added to reflect patients who receive telehealth in their home.

How is place of service determined?

According to the Medicare Claims Processing Manual, chapter 26, section 10.5, the POS is determined based on the patient's registration status at the time that the physician sees the patient.

What is the difference between place of service 31 and 32?

Use POS 31 when the patient is in a skilled nursing facility (SNF), which is a short-term care/rehabilitation facility. Use POS 32 when the patient is in a long-term nursing care facility.

What is place of service 99 used for?

Place of Service Description Laboratory A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician's office. 82-98 Unassigned N/A 99 Other Place of Service Other place of service not identified above. * Revised, effective April 1, 2004.

What is Field 11 in CMS 1500 claim form?

The street address, area, state, ZIP code, and telephone number are included. Box 11: This field requires the insured's policy or group number to be filled.

How to file a medical claim?

Follow the instructions for the type of claim you're filing (listed above under "How do I file a claim?"). Generally, you’ll need to submit these items: 1 The completed claim form (Patient Request for Medical Payment form (CMS-1490S) [PDF, 52KB]) 2 The itemized bill from your doctor, supplier, or other health care provider 3 A letter explaining in detail your reason for submitting the claim, like your provider or supplier isn’t able to file the claim, your provider or supplier refuses to file the claim, and/or your provider or supplier isn’t enrolled in Medicare 4 Any supporting documents related to your claim

What to call if you don't file a Medicare claim?

If they don't file a claim, call us at 1-800-MEDICARE (1-800-633-4227) . TTY: 1-877-486-2048. Ask for the exact time limit for filing a Medicare claim for the service or supply you got. If it's close to the end of the time limit and your doctor or supplier still hasn't filed the claim, you should file the claim.

How do I file a claim?

Fill out the claim form, called the Patient Request for Medical Payment form (CMS-1490S) [PDF, 52KB). You can also fill out the CMS-1490S claim form in Spanish.

What is an itemized bill?

The itemized bill from your doctor, supplier, or other health care provider. A letter explaining in detail your reason for submitting the claim, like your provider or supplier isn’t able to file the claim, your provider or supplier refuses to file the claim, and/or your provider or supplier isn’t enrolled in Medicare.

How long does it take for Medicare to pay?

Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't pay its share. For example, if you see your doctor on March 22, 2019, your doctor must file the Medicare claim for that visit no later than March 22, 2020.

What happens after you pay a deductible?

After you pay a deductible, Medicare pays its share of the Medicare-approved amount, and you pay your share (coinsurance and deductibles). , the law requires doctors and suppliers to file Medicare. claim. A request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered.

When do you have to file Medicare claim for 2020?

For example, if you see your doctor on March 22, 2019, your doctor must file the Medicare claim for that visit no later than March 22, 2020. Check the "Medicare Summary Notice" (MSN) you get in the mail every 3 months, or log into your secure Medicare account to make sure claims are being filed in a timely way.

What does Medicare expect from you?

Medicare expects you to evaluate the patient, determine their rehabilitation needs and address those needs. One of those inaccurate impressions is the belief the patient must be making objective progress in order to continue with rehabilitation.

How long is Medicare billing?

When billing timed CPT codes, Medicare not only looks at the individual 15-minute units but also considers the total time when factoring the allowable payment. This is commonly known as the 8-23-minute rule.

What is the TPE program?

CMS now uses the Target ed Probe and Educate program (TPE) to review selected claims and educate providers on Medicare billing requirements. Currently, the CMS is targeting only those practices with the highest denial rate or with billing practices that are substantially different than their peers.

What is the KX modifier threshold for PT/SLP?

Another misperception relates to the KX modifier threshold of $2080 for PT/SLP combined and the same for OT care in 2020. Numerous people still believe the KX modifier functions like a hard cap and discharge patients from their care once they’ve reached that “cap”. This is incorrect. The KX modifier simply indicates to Medicare that specific treatment continues to be medically necessary and requires the skills of the PT/OT in order to continue towards meeting the patient’s goals. This serves as a mental check on whether the care continues to be reasonable and necessary. Is the cost going to be worth the outcomes and is the treatment helping this patient either improve or not get worse?

How did Medicare come into existence?

Medicare came into being through legislation, signed into law by President Lyndon Johnson, as part of the Social Security Amendments of 1965. It’s funded by payroll deductions as an addition to your Social Security deductions (FICA) as well as premiums paid for those receiving Part B benefits.

What is the most important thing about Medicare?

One of the more valuable things about Medicare is they tell you exactly what they are looking for in their documentation requirements. For starters, documentation must support the medical necessity of the care provided. This means your notes must be comprehensive enough and contain sufficient detail so anyone reviewing the medical record may easily see what you are treating and why you are providing that specific treatment. They should also be able to easily see if there is progress towards achieving the patient’s functional goals.

Does Medicare cover rehabilitation?

Another rule for providing rehabilitation care to a patient with Medicare is the patient’s condition must be complex enough to require the skilled care and knowledge of a PT/OT. Medicare considers the definition of skilled care based on the individual therapist’s state statute.

Optimize Claims

The first step is to optimize your claims. Be sure to use an up to date practice management software that allows you to keep track of each patient’s information, including their insurance information. Be sure that when you are writing the SOAP notes for each patient, that the billing and diagnoses codes are cohesive.

Increase Efficiency

Increasing efficiency through a clearinghouse as discussed above is one way to start seeing more efficient workflows in your physical therapy practice. However, this is just the tip of the iceberg.

Digital Filing

Let’s face it, paper filing was great. But it had its day in the sun. The future is now, and the future is digital filing. Most insurance companies, Medicare included, will not accept paper claims. It’s simply not an efficient way to run an organization, and it costs businesses thousands of dollars each year to maintain a paper-only business.

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.

Why do you need to bill for physical therapy?

But in order to stay in business long enough to actually make a difference in your patients’ lives, you absolutely must bill—and collect payment— for your services.

How many minutes of therapy do you need to bill Medicare?

According to the rule, you must provide direct treatment for at least eight minutes in order to receive reimbursement from Medicare for time-based codes. Learn everything you need to know about the 8-Minute Rule.

When did CMS start reducing Medicare payments to therapists?

In 2011, CMS began reducing payments to therapists when they performed multiple therapeutic procedures on one patient during the same date of service. This policy is known as the Multiple Procedure Payment Reduction (MPPR). During the pioneer years of MPPR—January 1, 2011 to March 31, 2013—PTs, OTs, and SLPs saw a 20% reduction to the practice expenses (PE) they billed to Medicare for these “always covered” services. Since April 2013, that figure has increased significantly, as therapists now must contend with a 50% cut to their PE when performing these services. Learn four key things you should know about MPPR changes here and how to manage MPPR in your clinic here.

What is the most common claim form?

However, some payers—a dwindling few—do still accept paper ones. The most common form is the Universal Claim Form ( CMS 1500 ), although some payers may request that you use their own.

What is CPT medical?

Developed by the American Medical Association (AMA), the Current Procedural Terminology (CPT®) is “the most widely accepted medical nomenclature used to report medical procedures and services under public and private health insurance programs.”.

How long does it take for a physician to sign a plan of care?

Initial certification: Medicare requires ordering physicians to “approve or certify the plan of care via signature in a timely manner (within 30 days of the evaluation).”. The initial certification covers the first 90 days of treatment.

When do you need to apply modifier 59?

You may need to apply modifier 59 if you provide two wholly separate and distinct services during the same treatment period. Learn more about modifier 59 here.

What is Medicare Part B therapy?

Under the MPFS (Medicare Part B), Medicare pays for services provided by physicians and practitioners that are specifically authorized by statute. Students do not meet the definition of practitioners under Medicare Part B. Under SNF PPS, payments are based upon the case mix or RUG category that describes the patient. In the rehabilitation groups, the number of therapy minutes delivered to the patient determines the RUG category. Payment levels for each category are based upon the costs of caring for patients in each group rather than providing specific payment for each therapy service as is done in Medicare Part B

What is the coding system used for outpatient rehabilitation?

The HCPCS is the coding system used for the reporting of these services.

What is intra service care?

In other words, the time counted as “intra-service care” begins when the therapist or physician (or an assistant under the supervision of a physician or therapist) is directly working with the patient to deliver treatment services. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.

What is the HCPCS code for occupational therapy?

beneficiary received occupational therapy (HCPCS code 97530 which is defined in 15 minute intervals) for a total of 60 minutes. The provider would then report revenue code 043X in FL 42, HCPCS code 97530 in FL 44, and 4 units in FL 46.

What is the CMS 1450?

Effective with claims submitted on or after April 1, 1998, providers billing on Form CMS-1450 are required to report the number of units for outpatient rehabilitation and certain audiology services based on the procedure or service , e.g., based on the HCPCS code reported instead of the revenue code. This was already in effect for billing on the Form CMS-1500. CORFs report their full range of CORF services on the Form CMS-1500. Units are reported based on the number of times the procedure, as described in the HCPCS code definition, is performed. When reporting service units for HCPCS codes where the procedure is not defined by a specific timeframe, the provider enters “1” in units. Since providers may perform a number of procedures or services during a single visit, the number of units may exceed the number of visits. Visits should not be reported as units for these services.

Do OPTs bill for supplies?

OPTs should not bill for the supplies they furnish. Since supplies are part of the practice expense, under the MPFS these expenses are already taken into account in the practice expense relative values.

Can a physical therapist be a clinical instructor?

Physical therapist assistants and occupational therapy assistants are not precluded from serving as clinical instructors (CIs) for therapy students, while providing services within their scope of work and performed under the direction and supervision of a licensed physical or occupational therapist to a Medicare beneficiary.

How long does it take to submit a Medicare claim?

By its express terms, the Medicare Mandatory Claims Submission Rule states that “within 1 year after the date of providing a service for which payment is made under [Medicare] on a reasonable charge or fee schedule basis,” a supplier “shall complete and submit a claim for such service on a standard claim form.” [1] Failure to comply with the Medicare Mandatory Claims Submission Rule is subject to a civil monetary penalty of $2,000 per instance of noncompliance, among other penalties. [2]

What is a participating supplier in Medicare?

Participating Supplier – In Medicare vernacular, PTs are “suppliers.” A “participating supplier” is one who has an agreement with the Medicare program to “accept assignment” for all Medicare-covered services. By accepting assignment, a participating supplier agrees to accept the Medicare-approved amount as payment in full for Medicare-covered services.

What is an ABN in Medicare?

Advance Beneficiary Notice (ABN) – An ABN is a notice issued by a supplier prior to rendering services that the supplier believes will not be covered by Medicare because the supplier believes the service will not meet Medicare’s medical necessity requirement.

What is covered service?

Covered Service – A service that is “covered” by Medicare is one that falls within an authorized benefit category and meets the applicable requirements of the specific service. A universal requirement for Medicare coverage is that the service be “reasonable and necessary” or “medically necessary.”.

What is cash pay for physical therapy?

For many physical therapists (PT) , a cash-pay practice offers a refreshing alternative to a traditional practice model based on revenue from third-party payors. Under this model, patients simply pay for PT services at the point of service, based on rates set by the PT practice. To this end, the PT practice is spared the administrative burdens of billing and complying with the rules and regulations of third-party payor programs, including government programs like Medicare and Medicaid.

Is physical therapy a cash based practice?

One of the major draws of a cash-based physical therapy practice is avoiding the administrative hassles that come with participating in third-party payor programs, such as Medicare and Medicaid. But these practices should be cautioned: Even if they have no relationship at all with the federal Medicare program, they still may be subject to some of its rules, including what’s called the Medicare Mandatory Claims Submission Rule.

Does Medicare require a claim submission?

The Medicare Mandatory Claims Submission Rule does not apply to physicians and certain other categories of suppliers who have opted out of Medicare. Thus, these suppliers may bill a Medicare beneficiary for Medicare-covered services under a private contract that complies with Medicare’s opt-out requirements. [3] .

What is the CPT code for Medicare?

We're billing Medicare with CPT Codes 97110 (2 units) , 97161 and 97112 for an Eval.

What are the two digit modifiers for PT billing?

There are two overarching categories of PT billing modifiers: CPT modifiers: These are two-digit codes that apply to CPT codes. Level II HCPCS (Healthcare Common Procedure Coding System) modifiers: These are two-letter codes used by Medicare as well as some Medicaid and commercial plans.

What is CPT code 97530?

You’re treating a patient with an ankle sprain, and you’re billing 15 minutes of manual therapy (CPT code 97140) and 15 minutes of therapeutic activity (CPT code 97530) on the same date of service. Add the 59 modifier to code 97530, and it allows you to receive payment for both of these timed codes (provided you performed them during separate 15-minute increments).

What is a GP modifier?

GP modifier. The GP modifier indicates that a physical therapist’s services have been provided. It’s commonly used in inpatient and outpatient multidisciplinary settings. It’s also used for functional limitation reporting (FLR), as physical therapists must report G-codes, severity modifiers, and therapy modifiers.

Does Healthnet require modifier 59?

It sounds like Healthnet may require modifier 59 for some of these code combinations. However, you'll need to confirm this with the payer, so I recommend reaching out to Healthnet directly.

How long does it take to get a certified plan of care?

However, it does require that patients be under the care of a physician once treatment begins...You should only proceed with treatment, though, if you’re confident that you’ll be able to obtain a certified plan of care within that 30-day timeframe. Otherwise, you risk not receiving payment for your services.".

Do you need a modifier for a CPT code?

Yes. Many CPT codes must be accompanied by the GP modifier when provided under a physical therapy plan of care. When appropriate—that is, when one or more of those codes is part of an NCCI edit pair but the service was provided separately and independently of the linked service—modifier 59 can also be applied to the code.

When Do I Need to File A Claim?

• You should only need to file a claim in very rare cases
  Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't pay its share. For example, if you see your doctor on March 22, 2019, your doctor must file the Medicar…
• If your claims aren't being filed in a timely way:
  1. Contact your doctor or supplier, and ask them to file a claim. 2. If they don't file a claim, call us at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048. Ask for the exact time limit for filing a Medicare claim for the service or supply you got. If it's close to the end of the time limit and yo…

See more on medicare.gov

How Do I File A Claim?

What Do I Submit with The Claim?

Where Do I Send The Claim?