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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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  • Medicare Provider Participation and Non-Participation

    14 Jun 2023 2:24 PM | Zachary Edgar (Administrator)

    June 14, 2023

    Physical, occupational, and speech therapists can be participation or non-participating providers in Medicare.  PTs, OTs, and SLPs can also not enroll in Medicare at all but cannot be “opt-out providers” so the current rules are a little grey, more on this below.

    Participating Providers

    A participating provider is one who voluntarily and in advance enters into an agreement in writing to provide all covered services for all Medicare Part B beneficiaries on an assigned basis:

    • Agrees to accept Medicare-approved amount as payment in full;
    • May not collect more than applicable deductible and coinsurance for covered services from patient. 
    • Payment for non-covered services may also be collected;
    • Charges are not subject to limiting charge;
    • Medicare payment paid directly to the provider;
    • Mandatory claims submission applies;
    • Placement in Medicare Participating Physicians and Suppliers Directory (MEDPARD);
    • Reimbursement is 5 percent higher than the non-participating amount;
    • Medigap information is transferred; and
    • Patient referral service by hospital

    Non-Participating Providers

    A non-participating provider has not entered into an agreement to accept assignment on all Medicare claims:

    • Can elect to accept assignment or not accept assignment on a claim-by-claim basis;

    • Cannot bill the patient more than the limiting charge on non-assigned claims;
    • Beneficiary receives payment on non-assigned claims;
    • Mandatory claims submission applies;
    • Approved amount is 5 percent less than participating — even if assignment is accepted on the claim; and
    • Medigap information is not transferred.

    Opt-Out Providers

    Physician/Practitioners can choose to be opt-out providers which means they are not enrolled in Medicare, cannot bill Medicare, and instead must enter into a private contract with Medicare beneficiaries in order to collect payment directly from the beneficiary.  The physician/practitioner cannot choose to opt-out of Medicare for some Medicare beneficiaries but not others; or for some services but not others.  The physician/practitioner who chooses to opt-out of Medicare may provide covered care to Medicare beneficiaries only through private contracts.

    Physical therapists in independent practice, occupational therapists and speech therapists in independent practice cannot opt out because they are not within the opt out law’s definition of either a “physician” or “practitioner”.

    Unfortunately, Medicare has not been clear on the obligations of therapists who are not enrolled in Medicare as either participating or non-participating providers. 

    Medicare does provide us with this language:

    • The only situation in which non-opt-out physicians or practitioners, or other suppliers, are not required to submit claims to Medicare for covered services is where a beneficiary or the beneficiary’s legal representative refuses, of his/her own free will, to authorize the submission of a bill to Medicare.  However, the limits on what the physician, practitioner, or other supplier may collect from the beneficiary continue to apply to charges for the covered service, notwithstanding the absence of a claim to Medicare.
    • In some circumstances, a non-opt-out physician/practitioner, or other supplier, is required to provide an Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary prior to rendering an item or service that is usually covered by Medicare but may not be covered in this particular case.  The ABN notifies the beneficiary that Medicare will likely deny the claim and prompts the beneficiary to choose whether or not he/she will accept liability for the full cost of the services if Medicare does not pay.  The beneficiary also indicates on the ABN whether or not a claim should be submitted to Medicare.  Providers and suppliers must follow the beneficiary’s directive for claim submission as indicated on the ABN.  Providers and suppliers will not violate the mandatory claim submission rules of §1848(g)(4) of the Social Security Act when a claim is not submitted per a beneficiary’s written request on an ABN.  Where a valid ABN is given and a claim is submitted, subsequent denial of the claim relieves the non-opt-out physician/practitioner, or other supplier, of the limitations on charges that would apply if the services were covered.

    The language above indicates that non-opt-out therapists should use an ABN form to inform their clients that they are not enrolled in Medicare and that the client will be responsible for payment.  This is especially important when Medicare would otherwise cover the therapy services. 

    For services that Medicare never covers such as wellness or general exercise, an ABN is voluntary, however, it is still a good idea to use one because it puts the client on notice that they are responsible for payment and why.     

    See our Medicare ABN section for detailed instructions on how to use an ABN form.

    Reference

    Centers for Medicare and Medicaid.  Medicare Benefit Manual Ch. 15 § 40

    Novitas Solutions - Participating Provider Versus Non-Participating Provider

  • Aquatic Therapy

    14 Jun 2023 1:43 PM | Zachary Edgar (Administrator)

    Aquatic Therapy/Exercises – June 14, 2023

    CPT: 97113

    Aquatic therapy refers to any therapeutic exercise, therapeutic activity, neuromuscular re-education, or gait activity that is performed in a water environment including whirlpools, hubbard tanks, underwater treadmills and pools.

    When Reasonable and Necessary

    This procedure may be reasonable and necessary for the loss or restriction of joint motion, strength, mobility, balance or function due to pain, injury, or illness by using the buoyancy and resistance properties of water.

    Aquatic therapy may be considered reasonable and necessary for a patient without the ability to tolerate land-based exercises for rehabilitation. Aquatic therapy exercises should be used to facilitate progression to land based therapy. The qualified professional/personnel auxiliary personnel does not need to be in the water with the patient unless there is an identified safety issue.

    Indications

    Aquatic therapy with therapeutic exercise may be considered reasonable and necessary in the treatment of the following conditions:

    • The patient having pain, joint stiffness or muscle spasms resulting from rheumatoid arthritis
    • The patient having had a cast removed or recent surgery and requiring mobilization of limbs
    • The patient having paraparesis or hemiparesis
    • The patient having had a recent amputation
    • The patient recovering from a paralytic condition
    • The patient requiring limb mobilization after a head trauma
    • The patient having the inability to tolerate exercise for rehabilitation under gravity-based weight bearing
    • The patient having fibromyalgia

    Counting Minutes

    The aquatic therapy treatment minutes counted toward the total timed code treatment minutes should only include actual skilled exercise time that required direct one-on-one patient contact by the qualified professional/auxiliary personnel.

    Do not include minutes for the patient to dress/undress, get into and out of the pool, etc.

    Limitations

    Do not bill for the water modality used to provide the aquatic environment, such as whirlpool in addition to aquatic therapy/exercises.

    This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).

    Once a patient can demonstrate an exercise safely, therapists may no longer bill Medicare for the time it takes the patient to perform this now independent exercise.

    Exercises in the water environment to promote overall fitness, flexibility, improved endurance, aerobic conditioning, or for weight reduction are non-covered.

    Documentation

    Documentation must clearly support the need for aquatic therapy greater than eight (8) visits.

    • Justification for use of a water environment
    • Objective loss of ADLs, mobility, ROM, strength, balance, coordination, posture and effect on function
    • If used for pain include pain rating, location of pain, effect of pain on function
    • Specific exercises/activities performed (including progression of the activity), purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills and of a therapist were required.

    If the same exercise is performed over a number of sessions, the documentation must describe the skilled nature of the qualified professional’s/auxiliary personnel’s intervention during the therapeutic exercise to support the ongoing medical necessity.

    Community Pools

    When therapy services may be furnished appropriately in a community pool by a clinician in a physical therapist or occupational therapist private practice, physician office, outpatient hospital, or outpatient SNF, the practice/office or provider must rent or lease the pool, or a specific portion of the pool. 

    The use of that part of the pool during specified times needs to be restricted to the patients of that practice or provider.  The written agreement to rent or lease the pool must be available for review on request.  When part of the pool is rented or leased, the agreement must describe the part of the pool that is used exclusively by the patients of that practice/office or provider and the times that exclusive use applies. 

    Reference

    Centers for Medicare and Medicaid. Benefit Manual Chapter 15 § 220

    LCD: Outpatient Physical and Occupational Therapy Services - L34049

    LCD: Outpatient Physical Therapy - L34428

  • Group Therapy: PT, OT, SLP

    7 Jun 2023 12:22 PM | Zachary Edgar (Administrator)

    Group Therapy

    PT and OT: 97150

    SLP: 92508

    Report the group therapy code for each member of the group.  Group therapy procedures involve constant attendance of the therapist or assistant, but by definition do not require one-on-one patient contact.

    Group therapy consists of therapy treatment provided simultaneously to two (2) or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two (2) or more patients at the same time, 

    Examples of Group Therapy

    Example 1:  In a twenty-five (25) minute period, a therapist works with two patients, A and B, and divides his/her time between the two (2) patients.  The therapist moves back and forth between the two (2) patients, spending a minute or two at a time, and provides occasional assistance and modifications to patient A’s exercise program and offers verbal cues for patient B’s gait training and balance activities on the parallel bars. The therapist does not track continuous identifiable episodes of direct one-on-one contact with either patient. The appropriate coverage is one (1) unit for each patient.

    Example 2:  In a forty-five (45) minute period, a therapist works with three (3) patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence:  Patient A receives eight (8) minutes, patient B receives eight (8) minutes and patient C received eight (8) minutes.  After this initial twenty-four (24) minute period, the therapist returns to work with patient A for ten (10) more minutes (18 minutes total), then patient B for five (5) more minutes (13 minutes total), and finally patient C for six (6) additional minutes (14 minutes total).  During the times the patients are not receiving direct one-on-one contact with the therapist, they are each exercising independently. The therapist appropriately bills each patient one (1) fifteen (15) minute unit of therapeutic exercise.

    Limitations

    One (1) unit is appropriate per patient per visit.

    Groups should be limited to no more than four (4) group members.

    Group therapy should not represent the entire plan of treatment.

    Documentation

    If group therapy is billed on a given day, it must be listed in the treatment note. The minutes of this untimed code must be added to the Total Treatment Time for that day. Further documentation describing the skilled nature of the group session documented in the progress report or the treatment note may assist in supporting the medical necessity of the service.

    Supportive documentation recommendations for group therapy:

    • The purpose of the group and the number of participants in the group
    • Description of the skilled activity provided in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual.

    Services Not Covered

    Supervision of a previously taught exercise program or supervising patients who are exercising independently is not a skilled service and is not covered as group therapy or as any other therapeutic procedure. Supervision of patients exercising on machines or exercise equipment, in the absence of the delivery of skilled care, is not a skilled service and is not covered as group therapy or as any other therapeutic procedure.

    Non-covered as group therapy:

    • Groups directed by a student, therapy aide, rehabilitation technician, nursing aide, recreational therapist, exercise physiologist, or athletic trainer;
    • Routine (i.e., supportive) groups that are part of a maintenance program, nursing rehabilitation program, or recreational therapy program;
    • Groups using biofeedback for relaxation;
    • Viewing videotapes; listening to audiotapes;
    • Group treatment that does not require the unique skills of a therapist.

    Reference

    Centers for Medicaid and Medicare.  Benefit Manual Chapter 15 § 230

    LCD: Outpatient Physical and Occupational Therapy Services L34049

    LCD: Speech-Language Pathology L34046

  • Remote Therapeutic Monitoring FAQs

    17 May 2023 12:38 PM | Zachary Edgar (Administrator)

    What is Remote Therapeutic Monitoring (RTM)?

    Remote Therapeutic Monitoring (RTM) services monitor health conditions, including musculoskeletal system status, respiratory system status, therapy adherence, and therapy response.  RTM is intended for the management of patients utilizing medical devices that collect non-physiological data.

    Who can perform RTM services?

    RTM services can be performed by physical, occupational, and speech therapists.  Physical therapy and occupational therapy assistants may also perform RTM services under the supervision of their respective therapists.

    When services are performed by PTAs or OTAs, the CQ/CO modifiers must be used.

    What are the RTM codes and requirements for billing?

    CPT code 98975 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment.

    Report this code only once per episode of care and only if monitoring occurs over a period of at least 16 days. Use this code to report the initial time spent setting up and teaching the patient/caregiver how to use the device.

    Documentation should include the type of device being used, the specific education and training provided to the patient and/or caregiver, and any device set-up required.

    CPT code 98976 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily).

    Report this code only if monitoring a patient’s respiratory system, and only if the monitoring occurs over a period of at least 16 days.

    Documentation should include the name and description of the device provided for monitoring of the respiratory system.

    CPT code 98977 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days.

    Report this code only when monitoring the musculoskeletal system, and only if monitoring occurs over a period of at least 16 sequential days.

    Document the name and description of the device provided for monitoring of the musculoskeletal system.

    CPT code 98980 ─ Remote therapeutic monitoring treatment management services, physician/ other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes.

    Use to report the first 20-minute increment of time spent reviewing and integrating the data collected during remote monitoring to inform treatment goals; monitor the patient’s progress and adherence to the treatment plan; and provide clinical feedback to the patient/caregiver.

    Count cumulative time spent in data review and patient/caregiver interaction in a calendar month (not each 30 days). Report the base and add-on codes together on the claim, based on total time, at the end of each calendar month. The base code (98980) may only be reported once per calendar month. Don’t report CPT code 98980 unless a full 20 minutes of monitoring has occurred.

    Document the data gathered from the device, the date and time of the patient and/or caregiver interaction, and any decisions made that impact the treatment and plan of care as a result of the monitoring.

    CPT code 98981 ─ Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)

    Use to report each subsequent 20-minute increment of time spent reviewing and integrating the data collected during remote monitoring to inform treatment goals; monitor the patient’s progress and adherence to the treatment plan; and provide clinical feedback to the patient/caregiver. Don’t report CPT code 98981 unless a full additional 20 minutes of monitoring has occurred. CPT code 98980 must be billed if CPT code 98981 is being billed.

    What are the limitations for billing RTM codes?

    Code 98975 can be billed once per episode of care. An episode of care begins with the initiation of the RTM service and terminates when the targeted treatment goals have been achieved.

    Code 98976 and code 98977 can be billed once per 30 days.

    Code 98980 and code 98981 can be billed once per calendar month regardless of the number of therapeutic modalities furnished in that month.

    What kind of device must be used?

    The device used for RTM must fall under the FDA’s definition of a device:

    An instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part or accessory which is:

    • Recognized in the official National Formulary, or the United States Pharmacopoeia, or any supplement to them,
    • Intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease in man or other animals, or
    • Intended to affect the structure or any function of the body of man or other animals.

    The device should be either approved, cleared, or registered with the FDA.

    Check the devices status: Devices@FDA

    How does the data need to be transmitted? 

    Data can be transmitted automatically by the device or it can be self-reported by the patient.

    How much does Medicare reimburse for RTM services?

    These figures represent the national payment amount, payment will differ depending on your area.

    98975: $19.32

    98976: $50.15

    98977: $50.15

    98980: $49.48

    98981: $39.65

    Reference

    86 FR 64996

  • Therapy Services Incident to FAQs

    24 Apr 2023 10:33 AM | Zachary Edgar (Administrator)

    Who can provide therapy services other than physical, occupational, or speech therapists?

    Therapy services can be provided to Medicare patients by physicians and non-physician practitioners (NPPs) such as nurse practitioners and physician assistants if all of the other coverage requirements for therapy services have been met.

    What does therapy services provided “incident to” the services of a physician/NPP mean?

    Therapists who are not enrolled in Medicare may provide therapy services to Medicare patients under the physician/NPP’s NPI.

    Does the physician/NPP need to supervise the therapist?

    Yes.  Therapists billing incident to a physician/NPP must be directly supervised by the physician/NPP, this means the physician/NPP must be on-site but not necessarily in the same room.

    Can a therapist bill incident to another therapist?

    No.  There is no coverage for services provided incident to the services of a therapist.  A therapist who is not enrolled in Medicare cannot bill under the NPI of a therapist who is enrolled.

    Can assistants bill incident to a physician/NPP?

     No.  Assistants can only bill under the supervision of an enrolled physical or occupational therapist.  However, if a PT and PTA (or an OT and OTA) are both employed in a physician’s office, the services of the PTA, when directly supervised by the PT or the services of the OTA, when directly supervised by the OT may be billed by the physician group as PT or OT services using the PIN/NPI of the enrolled PT (or OT).

    If the PT or OT is not enrolled, Medicare will not pay for the services of a PTA or OTA billed incident to the physician’s service.

    Can other healthcare practitioners bill therapy services incident to a physician/NPP?

    Regardless of any state licensing that allows other health professionals to provide therapy services, Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology.

    The services of athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as therapy services.

    Reference

    Medicare Benefit Policy Manual

    Chapter 15 – Covered Medical and Other Health Services

    230.5 - Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Non-Physician Practitioners (NPP)

  • End of the Covid-19 Health Emergency and Therapy Services

    11 Apr 2023 9:36 AM | Zachary Edgar (Administrator)

    President Biden on Monday signed H.J.Res.7 terminating the national emergency over the COVID-19 pandemic, a month before the White House had said the president would unilaterally end national emergency declarations related to the pandemic. 

    The federal Public Health Emergency (PHE) for COVID-19 declared under section 319 of the Public Health Service Act, is not the same as the COVID-19 National Emergency declared by the Trump Administration in 2020 and implicated by H.J.Res.7.  

    An end to the COVID-19 National Emergency does not impact current operations at HHS, and does not impact the planned May 11, 2023 expiration of the federal PHE for COVID-19 or any associated unwinding plans. 

    Virtual Supervision

    CMS temporarily changed the definition of “direct supervision” to allow the supervising health care professional to be immediately available through virtual presence using real-time audio/video technology instead of requiring their physical presence. CMS also clarified that the temporary exception to allow immediate availability for direct supervision through virtual presence also facilitates the provision of telehealth services by clinical staff “incident to” the professional services of physicians and other practitioners.  This provision applies to physical and occupational therapists supervising assistants in private practice.

    This flexibility will expire on December 31, 2023.

    Medicare and Telehealth

    During the PHE, individuals with Medicare had broad access to telehealth services, including in their homes, without the geographic or location limits that usually apply as a result of waivers issued by the Secretary, facilitated by the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, and the Coronavirus Aid, Relief, and Economic Security Act. “Telehealth” includes services provided through telecommunications systems (for example, computers and phones) and allows health care providers to give care to patients remotely in place of an in-person office visit.

    The Consolidated Appropriations Act, 2023, extended many telehealth flexibilities through December 31, 2024, such as:

    •  People with Medicare can access telehealth services in any geographic area in the United States, rather than only those in rural areas.
    • People with Medicare can stay in their homes for telehealth visits that Medicare pays for rather than traveling to a health care facility.
    • Certain telehealth visits can be delivered audio-only (such as a telephone) if someone is unable to use both audio and video, such as a smartphone or computer.

    List of Telehealth Services

    Reference

    CMS Waivers, Flexibilities, and the Transition Forward from the COVID-19 Public Health Emergency


  • Medicare Requirements when PT/OT Students are Involved in Patient Care

    25 Jan 2023 1:09 PM | Zachary Edgar (Administrator)

    The rules for therapy students are different in outpatient and inpatient settings.

    Medicare Outpatient Settings – Part B

    Only the services of the therapist can be billed and paid under Medicare Part B. The services performed by a student are not reimbursed even if provided under “line of sight” supervision of the therapist; however, the presence of the student “in the room” does not make the service unbillable.  Group therapy services performed by a therapist or physician may also be billed when a student is also present “in the room”.

    Medicare will pay only for the direct (one-to-one) patient contact services of the physician or therapist provided to Medicare Part B patients.   

    Therapists may bill and be paid for the provision of services in the following scenarios:

    • The qualified practitioner is present and in the room for the entire session.
    • The student participates in the delivery of services when the qualified practitioner is directing the service, making skilled judgment, and is responsible for the assessment and treatment.
    •  The qualified practitioner is present in the room guiding the student in service delivery when the therapy student and the therapy assistant student are participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.
    • •The qualified practitioner is responsible for the services and as such, signs all documentation. (A student may contribute to the documentation but it must be reviewed and signed by the supervising therapist or assistant).

    When a therapy student is involved the skilled minutes of the qualified clinician may be counted and coded when all requirements listed above are met.

    Therapy Assistants as Clinical Instructors

    PTAs and OTAs are not precluded from serving as clinical instructors 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.

    Medicare Inpatient Settings – Part A

    Therapy Students

    Therapy students are not required to be in line-of-sight of the supervising therapist/assistant. The determination of whether or not a student is ready to treat patients without line-of-sight supervision is left to the discretion of the supervising therapist/assistant.

    Time may be coded on the Minimum Data Sets (MDS) when the therapist provides skilled services and direction to a student who is participating in the provision of therapy. All state and professional practice guidelines for student supervision must be followed.

    Individual Therapy

    Individual therapy is for treatment of one (1) patient at a time. When a therapy student is involved the minutes may be coded when only one (1) patient is being treated by the therapy student and the supervising therapist/assistant.

    The supervising therapist/assistant cannot be treating or supervising another individual and he/she must be available to immediately assist the student as needed.

    Concurrent Therapy

    Concurrent therapy is for treatment of two (2) residents who are performing different activities at the same time and are both in line-of sight of the treating therapist/assistant.

    When a therapy student is involved the minutes may be coded when one of the following occurs:

    • Student is treating one (1) patient and the supervising therapist/assistant is treating another patient and both patients are in line of sight of the therapist/assistant or student; or
    • Student is treating two (2) patients both of whom are in line-of-sight of the student and the therapist/assistant is not treating any patients and is not supervising other individuals; or
    • Student is not treating any patients and the supervising therapist/assistant is treating two patients at the same time both of whom are in line-of-sight.

    Group Therapy

    Group therapy is for treatment of four (4) patients who are performing the same or similar activities and are supervised by a therapist/assistant who is not supervising any other individuals.

    When a therapy student is involved with group therapy the minutes may be coded when one of the following occurs:

    • Student is providing group treatment and the supervising therapist/assistant is not treating any patient and is not supervising other individuals (students or patients); or
    • Supervising therapist/assistant is providing group treatment and the student is not treating any patient.

    Reference

    Medicare LCA: Billing and Coding: Therapy Students and Aides A53339

    Medicare Benefit Policy Manual Ch. 15 § 230

  • Medicare Total Time Rule v. The AMA 8-Minute Rule

    11 Jan 2023 2:36 PM | Zachary Edgar (Administrator)

    The unit chart is the same for both systems.

    > 8 minutes through 22 minutes

    1 Unit

    > 23 minutes through 37 minutes

    2 Units

    > 38 minutes through 52 minutes

    3 Units

    > 53 minutes through 67 minutes

    4 Units

    > 68 minutes through 82 minutes

    5 Units

    > 83 minutes through 97 minutes

    6 Units

    > 98 minutes through 112 minutes

    7 Units

    > 113 minutes through 127 minutes

    8 Units

    Medicare Total Time Rule

    Step 1: Add together the time spent on all timed services during the therapy visit.  That amount of time will determine the total amount of units you can bill based on the chart above.

    Step 2: Allocate the units to each separate service. When determining the allocation of units, it is easiest to separate out each service first into “15-minute time blocks”.  Any timed service provided for at least 15 minutes, must be billed one unit. Any timed service provided for at least 30 minutes, must be billed two units, and so on.

    Step 3: If there are at least 8 extra minutes left over then you can allocate the extra unit to the service that you spent the most time on.

    Example

    20 minutes (1 unit) of Therapeutic Exercise (97110) and 35 minutes (2 units) of Neuromuscular Reeducation (97112) = 55 minutes or 4 units

    Under Medicare’s Total-Time rule that extra unit is allocated to 97112, so 3 units instead of 2.

    The AMA Rule

    Instead of adding the total session time for all time-based codes used, each service is considered separately, extra minutes are discarded rather than added to one of the services. 

    Example

    20 minutes (1 unit) of Therapeutic Exercise (97110) and 35 minutes (2 units) of Neuromuscular Reeducation (97112)

    Under the AMA rule you do not add up the total time so each procedure is separate.  You would only be able to bill for 3 units, 1 for 97110 and 2 for 97112.

    Example 1

    20 minutes of neuromuscular reeducation, 97112

    20 minutes therapeutic exercise, 97110

    = 40 minutes total treatment time

    Each code contains one 15-minute block, therefore, each code shall be billed for at least 1 one unit. As 3 units is allowed, a review of the “remaining minutes” is required to determine which code should be billed the additional unit. Since the “remaining minutes” for each service are the same in this example, either of the codes may be billed for the additional unit.

    The correct coding is either one of the following:

    Medicare: 2 units 97112 + 1 unit 97110 OR 1 unit 97112 + 2 units 97110

    AMA: 1 unit of 97112 + 1 unit of 97110

    Example 2

    24 minutes of neuromuscular reeducation, code 97112 (2 units)

    23 minutes of therapeutic exercise, code 97110 (2 units)

    = 47 total minutes.

    Utilizing the chart above, 47 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first:

    24 minutes 97112 = one 15-minute block + 9 remaining minutes

    23 minutes 97110 = one 15-minute block + 8 remaining minutes

    Each code contains one 15-minute block; therefore, each code shall be billed for at least 1 unit. Since the total minutes allows for 3 units, the third unit shall be applied to the service with the most “remaining minutes” (97112 has 9 remaining minutes, whereas, 97110 has 8 remaining minutes).

    Medicare: 2 units 97112 + 1 unit 97110

    AMA: 2 units 97112 +2 units of 97110

    Example 3

    36 minutes therapeutic exercise (CPT 97110)

    7 minutes manual therapy (CPT 97140)

    = 40 total minutes

    Utilizing the chart above, 40 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first:

                36 minutes 97110 = two 15-minute blocks + 6 remaining minutes

                7 minutes 97140 = zero 15-minute blocks + 7 remaining minutes

    Code 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the “remaining minutes”, and apply the additional unit to the service with the most remaining minutes.

    Medicare: 2 units 97110 + 1 unit 9714

    AMA: 2 units of 97110

    Example 4

    18 minutes of therapeutic exercise (CPT 97110)

    13 minutes of manual therapy (CPT 97140)

    10 minutes of gait training (CPT 97116)

    8 minutes of ultrasound (CPT 97035)

    = 49 total minutes

    Appropriate billing for a total of 49 minutes is 3 units. To allocate those 3 units, determine the 15-minute blocks first:

    18 minutes 97110 = one 15-minute block + 3 remaining minutes

    13 minutes 97140 = zero 15-minute blocks + 13 remaining minutes

    10 minutes 97116 = zero 15-minute blocks + 10 remaining minutes

    8 minutes 97035 = zero 15-minute blocks + 8 remaining minutes

    Code 97110 shall be billed for at least one unit as it contains one 15-minute block. The additional 2 units billable (for a total of 3 units for the day), must be applied to the services with the greatest remaining minutes.

    Medicare: 1 unit 97110 + 1 unit 97140 + 1 unit 97116

    AMA: 4 units, one each

    Example 5

    4 minutes assessing shoulder strength prior to initiating and progressing therapeutic exercise (CPT 97110)

    32 minutes therapeutic exercise (CPT 97110)

    7 minutes manual therapy (CPT 97140)

    = 43 total minutes

    Utilizing the chart above, 43 minutes falls within the range for 3 units. To allocate those 3 units determine the 15-minute blocks first:

    36 minutes 97110 = two 15-minute blocks + 6 remaining minutes

    7 minutes 97140 = zero 15-minute blocks + 7 remaining minutes

    Code 97110 must be billed for at least 2 units as it contains two 15-minute blocks. To determine the allocation of the third unit, compare the “remaining minutes”, and apply the additional unit to the service with the most remaining minutes. The correct coding is:

    Medicare: 2 units 97110 + 1 unit 97140

    AMA: 2 units of 97110

    Reference

    Local Coverage Article:

    Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)


  • Multiple Procedure Payment Reduction (MPPR)

    21 Dec 2022 1:42 PM | Zachary Edgar (Administrator)

    Posted December 21, 2022

    2023 MPPR Rate File

    How does the Multiple Procedure Payment Reduction (MPPR) work?

    Medicare applies a multiple procedure payment reduction (MPPR) to the practice expense (PE) payment of select therapy services.

    This means that full payment is made for the unit or procedure with the highest PE RVU payment.

    For subsequent units and procedures furnished to the same patient on the same day, full payment is made for work and malpractice and 50% percent payment cut is made for the PE for services submitted on either professional or institutional claims.

    Which codes/services does the MPPR apply to?

    The reduction applies to the HCPCS codes contained on the list of “always therapy” services regardless of the type of provider or supplier that furnishes the services.

    The MPPR applies to all therapy services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines, for example, physical therapy, occupational therapy, or speech-language pathology.

    2023 Therapy Code List and Dispositions

    Does the payment reduction apply to different services or to units of the same service as well?

    The reduction applies to both procedures and units.  If the services with the highest PE RVU is a timed code, the first unit will receive full payment and subsequent units will receive the reduced payment. 

    Example

    Code

    Rate

    PE RVU

    Ranking

    Final Allowable Amount

    Code A

    $96.80

    1.05

    1

    $96.80

    Code B

    $40.40

    .36

    2

    PE value = 35% x $40.40 = $14.14 x 50% or $7.07.

    Allowable Amount = $40.40 - $7.07 or $33.33

    Total

    $137.20

    $96.80 + $33.33 = $130.13

    Sample PE RVU Numbers

    The code with the highest PE RVU # will be paid in full, subsequent procedures or units will be reduced.

    Code

    Description

    PE RVU

    97610

    Low frequency non-thermal us

    11.52

    97597

    Rmvl devital tis 20 cm/<

    2.12

    97161

    PT evaluation

    1.33

    97165

    OT evaluation

    1.24

    97530

    Therapeutic activities

    0.67

    97112

    Neuromuscular reeducation

    0.49

    97110

    Therapeutic exercise

    0.40

    97108

    Paraffin bath

    0.16

    Reference

    Medicare Claims Processing Manual

    Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Services §10.7

  • Medicare Progress Report FAQs

    23 Nov 2022 3:27 PM | Zachary Edgar (Administrator)

    Posted on November 23, 2022

    See our Medicare Progress Report section for more information.

    Who must complete the progress report?

    Information required in progress reports shall be written by a clinician that is, either the physician/NPP who provides or supervises the services, or by the therapist who provides the services and supervises an assistant.

    Who must sign the report?

    The clinician who completed the report must sign and date report.

    It is not required that the referring or supervising physician/NPP sign the progress reports written by a PT, OT or SLP.

    When does the progress report need to be completed?

    The minimum progress report period shall be at least once every ten (10) treatment days. The day beginning the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation, reevaluation or treatment.

    The next treatment day begins the next reporting period. The progress report period requirements are complete when both the elements of the progress report and the clinician’s active participation in treatment have been documented.

    What happens if the patient is absent during the report period?

    Holidays, sick days or other patient absences may fall within the progress report period. Days on which a patient does not encounter qualified professional or qualified personnel for treatment, evaluation or re-evaluation do not count as treatment days.

    Absences do not affect the requirement for a progress report at least once during each progress report period. If the patient is absent unexpectedly at the end of the reporting period, when the clinician has not yet provided the required active participation during that reporting period, a progress report is still required, but without the clinician’s active participation in treatment, the requirements of the progress report period are incomplete.

    What happens if the report is delayed?

    If the clinician has not written a progress report before the end of the progress reporting period, it shall be written within 7 calendar days after the end of the reporting period. If the clinician did not participate actively in treatment during the progress report period, documentation of the delayed active participation shall be entered in the treatment note as soon as possible. The treatment note shall explain the reason for the clinician’s missed active participation. Also, the treatment note shall document the clinician’s guidance to the assistant or qualified personnel to justify that the skills of a therapist were required during the reporting period. It is not necessary to include in this treatment note any information already recorded in prior treatment notes or progress reports.

    What does active participation mean?

    Active participation of the clinician in treatment means that the clinician personally furnishes in its entirety at least 1 billable service on at least 1 day of treatment.

    Verification of the clinician’s required participation in treatment during the progress report period shall be documented by the clinician’s signature on the treatment note and/or on the progress report. When unexpected discontinuation of treatment occurs, contractors shall not require a clinician’s participation in treatment for the incomplete reporting period.

    Can the progress report be part of that day’s treatment note?

    Elements of progress reports may be written in the treatment notes if the provider/supplier or clinician prefers. If each element required in a progress report is included in the treatment notes at least once during the progress report period, then a separate progress report is not required.

    What must be included in the progress report?

    Progress reports shall include:

    •        Date of the beginning and end of the reporting period that this report refers to;

    •        Date that the report was written (not required to be within the reporting period);

    •        Signature, and professional identification, or for dictated documentation, the identification of the qualified professional who wrote the report and the date on which it was dictated;

    •        Assessment of improvement, extent of progress (or lack thereof) toward each goal;

    •        Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions should be documented in the clinician’s progress report; and

    •        Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment.

    •        Objective reports of the patient’s subjective statements, if they are relevant. For example, “Patient reports pain after 20 repetitions”. Or, “The patient was not feeling well on 11/05/06 and refused to complete the treatment session.”; and

    •        Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment, if they occur. Note that assistants may not make clinical judgments about why progress was or was not made, but may report the progress objectively. For example: “increasing strength” is not an objective measurement, but “patient ambulates 15 feet with maximum assistance” is objective.

    How can the progress report be used to justify medical necessity?

    Care must be taken to assure that documentation justifies the necessity of the services provided during the reporting period, particularly when reports are written at the minimum frequency. Justification for treatment must include, for example, objective evidence or a clinically supportable statement of expectation that:

    •        In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

    •        In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.

    Objective evidence consists of standardized patient assessment instruments, outcome measurements tools or measurable assessments of functional outcome. Use of objective measures at the beginning of treatment, during and/or after treatment is recommended to quantify progress and support justifications for continued treatment. Such tools are not required, but their use will enhance the justification for needed therapy.

    Can an assistant participate in the report?

    PTAs or OTAs may write elements of the progress report dated between clinician reports. Reports written by assistants are not complete progress reports. The clinician must write a progress report during each progress report period regardless of whether the assistant writes other reports. However, reports written by assistants are part of the record and need not be copied into the clinicians report.

    References

    Medicare Benefit Policy Manual Ch. 15 – Covered Medical and Other Health Services § 220.3

    Billing and Coding: Outpatient Physical and Occupational Therapy Services: A57067


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