Medicare Physical Therapy Guidelines 2021

The 9% Cut Is Here To Stay

Lets get the biggest bombshell out of the way: CMS is moving forward with the payment increases to evaluation and management services, and to pay for those increases, it will cut the conversion factor from $36.0896 to $32.4085. Ultimately, this means the 9% cut to PT, OT, and SLP services is officially happening.

When asked about these payment changes during a press call, CMS Administrator Seema Verma said, Primary care providers are not being reimbursed appropriately for the time that they are spending with patients, and so we cant continue to penalize those providers while continuing to have increases for providers that are doing more procedures. At the end of the day, we are reimbursing all providers for the time that they spend with patients. While many affected providers have pleaded with CMS to reconsider these cuts in light of pandemic-related financial troubles, according to the above-linked article, Verma also said that the problems providers face from COVID-19 have already been handled.

The 8 Minute Rule And Medicare: Your Guide To Physical Therapy Billing

The ability to navigate the rehabilitation billing practices and procedures of the federally regulated Centers of Medicare and Medicaid services has never been so important to the profession of physical therapy. Currently, there are approximately 44 million individuals enrolled in Medicare. As the baby boom generation ages, the Medicare population is projected to grow to 79 million by 2030, more than double the year 2000 enrollment. The increase in volume will challenge how the system proceeds to cover physical therapy and billing practices of healthcare practitioners.

In December 1999, the Health Care Financing Administration announced that as of April 1, 2000, the 8 minute rule must be used to bill Medicare beneficiaries for outpatient therapy services, according to Transmittal 747. The system applies to therapeutic services involving direct patient contact from the provider. A unit was re-defined as the number of times the service reported was performed.

Eventually, Transmittal 747 came to be known as Medicare’s 8 minute rule.

What is the 8 minute rule? The 8 minute rule is the current procedure for billing physical therapy services to Medicare. The 8 minute rule applies to direct contact therapeutic services in which a PT provides one on one services to a patient for at least eight minutes. Timed CPT codes are broken into units based on time intervals.

Medicare Coverage For Inpatient Physical Therapy

Medicare Part A covers medically necessary inpatient physical therapy at inpatient rehabilitation facilities sometimes called an inpatient rehab facility , acute care rehabilitation center or rehabilitation hospital.

You will still be responsible for a deductible, coinsurance and copayments.

Your Costs When Medicare Covers Physical Therapy 2022

Days 1 to 60

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Is Physical Therapy Covered By Medicaid

With Medicaid coverage, federal law requires states to provide certain mandatory benefits, and gives states the ability to choose whether or not they cover additional optional benefits.

While mandatory services include inpatient and outpatient hospital services, physician services, labs and x-ray services, and some home health services, physical therapy is an optional benefit. This means your state may or may not cover physical therapy services.

Even if your state does cover physical therapy, you may have an additional required copay or limitations on service, such as:

• Only a certain number of visits are covered per year
• Services must take place in certain locations, such as in home or your doctors office
• A maximum cost for outpatient services
• Prior authorization required

Kx Modifier And Exceptions Process

If services exceed the annual threshold amounts, claims must include the KX modifier as confirmation that services are medically necessary as justified by appropriate documentation in the medical record. There is one amount for PT and SLP services combined and a separate amount for OT services. This amount is indexed annually by the Medicare Economic Index .

For 2022 this KX modifier threshold amount is:

• $2,150 for PT and SLP services combined, and
• $2,150 for OT services.

For 2021 this KX modifier threshold amount is:

• $2,110 for PT and SLP services combined, and
• $2,110 for OT services.

The threshold process consists of 2 tiers:

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Medicare’s 2021 Proposed Final Rule Has Been Released

Trending with previous years, the proposed final rule was late this year – coming in August instead of July when it normally comes in. The 2021 CMS proposed final rule has been released. The proposed rule has some changes for physical therapy practices, occupation therapy practices, and speech practices as well. Typically, the proposed rule is left out there for comment and then ultimately a final rule is adopted later in the year . The rule will go into effect January 1, 2021.There are main areas that are of interest to private physical therapy and occupational therapy practices are:2021 Fee ScheduleMaintenance TherapyTelehealthMIPSKeep reading to learn more about where these areas are in the proposed final rule.This is a proposed rule is hot of the presses and is nearly 1,360 pages long. More details will come as the document can be reviewed. This information is provided based on a read of the proposal but is subject to further interpretation and updates.

A Change In Medicare Has Therapists Alarmed

Medicare revamped its reimbursement policy for physical, occupational and speech therapy in nursing homes. That has left some patients with less help.

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By Paula Span

In late September, a woman in her 70s arrived at a skilled nursing facility in suburban Houston after several weeks in the hospital. Her leg had been amputated after a long-ago knee replacement became infected she also suffered from diabetes, depression, anxiety and general muscular weakness.

An occupational therapist named Susan Nielson began working with her an hour a day, five days a week. Gradually, the patient became more mobile. With assistance and encouragement, she could transfer from her bed to a wheelchair, get herself to the bathroom for personal grooming and lift light weights to build her endurance.

That progress ended abruptly on Oct. 1, when Medicare changed its payment system for physical, occupational and speech therapy in nursing homes. Ms. Nielson, employed by Reliant Rehabilitation, which supplies therapists to almost 900 nursing facilities, said that her allotted time with the woman was reduced from 60 minutes to just 20 or so minutes a day, not even long enough to help her leave her bed.

Im not able to do my job, Ms. Nielson said. This person had the potential to do more, and I couldnt help her.

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Collect Copayments At The Time Of Service

Medicare has a copayment of 20% of the Medicare-approved amount under Medicare Part B . The Medicare-approved amount is the amount you as the physical therapist agree to be paid for services rendered, and the client is responsible for the remaining 20%.

You should avoid waiving copays or deductibles, although you can offer financial assistance if necessary.

Implementation Of The Bipartisan Budget Act Of 2018

This section was last revised in November 2021 to reflect the CY 2022 KX modifier thresholds and to add information from the CY 2022 physician fee schedule final rule on section 53107 of the Bipartisan Budget Act of 2018. On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. This law included two provisions related to Medicare payment for outpatient therapy services including physical therapy , speech-language pathology , and occupational therapy services:

• Section 50202 of the BBA of 2018 repeals application of the Medicare outpatient therapy caps and its exceptions process while adding limitations to ensure payment for appropriate therapy services. For related information see the CMS link to Medicare Expired Legislative Provisions Extended and Other Bipartisan Budget Act of 2018 Provisions .”
• Section 53107 of the BBA of 2018 relates to the payment of OT and PT services furnished by therapy assistants.

• $2,150 for PT and SLP services combined, and
• $2,150 for OT services.

• CQ modifier: PT services furnished in whole or in part by PTAs and
• CO modifier: OT services furnished in whole or in part by OTAs.

For CY 2022, in response to stakeholders concerns and to promote appropriate care, CMS revised the de minimis policies and defined 2 exceptions when the de minimis standard is not applied:

For more information about other outpatient therapy payment policies, please see:

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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.

Mips Mvps And The Future Of Medicare Reimbursements

CMS has gradually been taking steps to transition from service-based to value-based reimbursement models. Currently, CMS offers payment bonuses or penalties to eligible Part B rehabilitative therapy clinics through the Merit-Based Incentive Payment System . Over a gradual rollout of the program, MIPS is designed to reward clinics based on their performance within four categories: quality, advancing care information, improvement activities, and cost or resource use.

Whether you receive a negative or positive adjustment depends on objectives called MVPs . You can receive higher reimbursement by successfully completing MVP activities and measures. If youre curious to learn more about participating in MIPS or MVPs, check out our MIPS 101 blog post, or visit our partner Keet Health, a QCDR-certified application for rehab therapists.

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What Are The Medicare Rules For Physical Therapy

In the past, Medicare paid physical therapists based on the number of visits and time spent with patients. Since then, Medicare adopted a value-based approach to physical therapy to keep costs down and improve care. Physical therapy doctors are now paid based on a complex formula that considers several patients needs factors.

Doctors can authorize up to 30 days of physical therapy at a time. But, if you need physical therapy beyond those 30 days, your doctor must re-authorize it.

Frequently Asked Questions And Answers

What are some popular services for physical therapy?

Some popular services for physical therapy include:

What are people saying about physical therapy in Ontario, CA?

This is a review for physical therapy in Ontario, CA:

“Form and Funtion just gained another talented therapist named Patrick! Patrick is Form and Funtion’s new hidden Gem with years of knowledge and expertises. Patrick is personable and willing to listen to all your needs. He tailors each session towards your concerns and works each area accordingly. His hands and techniques are nothing short of magic and pure bliss… he knows how to fix his clients and ensures you’re walking away better than you came in! He focuses on healing you and not just temporary fixing you. He is truly a blessing! If you have not booked with Patrick I don’t know what your waiting for!”

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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 .

What If Your Physical Therapy Isnt Medically Necessary

Your provider must notify you before providing care that is not medically necessary so you can decide whether you want the services. This is true for physical therapy, speech-language pathology and occupational therapy. This notice is called an Advance Beneficiary Notice of Noncoverage . If your provider gives you an ABN, you may agree to pay for the services that arent medically necessary. However, Medicare will not help cover the cost.

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What Are The Medicare Caps For Physical Therapy Coverage

Medicare no longer caps medically necessary physical therapy coverage. For outpatient therapy in 2022, if you exceed $2,150 with physical therapy and speech-language pathology services combined, your therapy provider must add a modifier to their billing to show Medicare that you continue to need and benefit from therapy.

What drives whether or not Medicare will continue to help pay for your physical therapy is its effect on your condition and ability to function without pain or decline. You may receive physical therapy as an inpatient service covered by Part A or an outpatient, preventive service covered by Part B. It is up to the therapist, facility, or agency to bill Medicare using the correct billing codes. Medicare requires documentation that shows your progress and needs for ongoing therapy.

Billers Beware: Ncci Edit Pairs And Mppr Impacts

Two common hurdles for Medicare billing are the National Correct Coding Initiative code edits and the multiple procedure payment reduction . Both of these compliance topics can negatively impact practice revenue if not followed correctly.

NCCI code edits consist of a list of CPT codes that should not be billed together, otherwise known as procedure-to-procedure edits. If code pairs appear on a claim, they can trigger an immediate denial for reimbursement. NCCI also blocks medically unlikely edits , which occur when your claim exceeds the maximum service units for a single person on the same day. NCCI edits update annually and have a history of causing claim issues as clinics adapt to new PTP edits. We talk about that history and other compliance concerns for clinics on our NCCI Edits guide.

MPPR decreases the practice expense portion of a reimbursement by 50% when multiple units of specific services considered always therapy are billed together on a claim. MPPR reduces practice payment received for every service provided to a patient after the first in a single day, even when your patient saw providers in multiple rehab disciplines. There are ways clinics can mitigate the impact of MPPR, which we discuss further in our MPPR guide.

Also Check: What To Expect At Physical Therapy

When Do I Use The Kx Modifier

The KX modifier should be applied whenever furnished services exceed the annual threshold amount. So, the KX modifier for physical therapy should be applied when services total above $2,150 â either individually or paired with SLP services. This modifier confirms that services were medically necessary and justified, to safeguard potential reimbursement.

There are several instances when a PT would require the KX modifier:

• A complex, single episode of care that necessitated therapy above the threshold, such as a complex shoulder rehabilitation.
• A combined, single episode of care that involved both PT and SLP services, such as rehabilitation after a stroke.
• Multiple episodes of care for a rehab diagnosis that requires additional therapy, such as total knee replacement rehabilitation followed by strengthening and flexibility services.

Two 8 Minute Rule Billing Scenarios

Example 1:

We can take a look at a scenario in which a physical therapist bills according to the individual units versus total time. If the therapist performs 35 minutes of therapeutic exercise and 33 minutes of therapeutic activity but only bills 4 units, they are actually missing out on the benefit of looking at total time. If you add the time for each service, it adds up to 68 minutes for which you can bill five units. for therapeutic exercise and 2 units for therapeutic activity). Leaving 5 minutes and 3 minutes left over which adds up to 8 minutes. The larger amount of minutes leftover goes to therapeutic exercise where you can now bill three units of therapeutic exercise and as two units of therapeutic activity.

Example 2:

Say a therapist performs manual therapy for 7 minutes. Manual therapy is a time-based code, but in this case the time is not greater than or equal to 8 minutes. On its own, a therapist would not be able to bill for this treatment. However, if 22 minutes of therapeutic exercise are performed as well then the added time is equal to 29 minutes and can be billed for two units instead of one.

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Medicare Audits And Other Concerns

As a provider, you are expected by CMS to know and follow the complicated Medicare rules for rehabilitative therapy. In addition to a claim being denied or delayed, CMS can also audit your practice if certain red flags are raised due to billing practices or documentation issues.

Preparing for a Medicare audit requires you to invest a great deal of time and money, and willingly participating in an audit doesnt guarantee that youll avoid fines and penalties from CMS, either.

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.

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