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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 FAQs

Frequently asked questions on Medicare's coverage of therapy services.  These are just sample FAQs, please take a look at our other sections for more comprehensive FAQs and guides.   

Criteria for Coverage

    • What conditions are required to furnish outpatient therapy for Medicare patients?
    • How do I demonstrate that the patient needs therapy services?
    • How do I show that the plan is periodically reviewed by a physician/NPP?
    • How can I document that the patient is or was under the care of a physician?

Orders/Referrals

    • Does Medicare require an order or referral?
    • Does Medicare require that the patient visit the physician?
    • Which providers can certify a POC?
    • Which providers cannot certify a POC?

Evaluations/Reevaluations

    • Who can perform a therapy evaluation?
    • When does an evaluation need to be performed?
    • Can an evaluation and treatment be performed on the same visit?
    • What must be included in the evaluation?

Progress Reports

    • Who must complete the progress report?
    • Who must sign the report?
    • When does the progress report need to be completed?
    • What happens if the report is delayed?

Discharge Summary

    • Is a discharge summary required for every patient?
    • What if the patient just stops coming to therapy?
    • What is required on the discharge summary?

Assistants

    • What level of supervision is required for PTAs and OTAs?
    • Are services provided by SLPA covered?
    • Can PTAs and OTAs perform services incident to a physician/NPP?
    • What role can PTAs and OTAs take part in the progress report?

Appeals


Medical Necessity

    • When are services considered to be medical necessary under Medicare rules?
    • When are services considered to not be medically necessary?
    • What should be included in a POC for rehabilitative therapy?
    • What conditions are required in order for a maintenance program to be covered?

Certification/Recertification 

    • What does Medicare require for a certification?
    • When does the POC need to be certified?
    • Can the certification be done verbally?
    • When is recertification required?

Plan on Care

    • Who can establish a therapy plan of care (POC)?
    • Who must sign the POC?
    • Can treatment begin before a POC has been established?
    • What must be included in the POC?

Treatment Notes

    • When are treatment notes required?
    • What is required to be included in the treatment note?
    • Who must sign the treatment note?
    • Does the supervisor’s signature need to be on the note?

Modifiers

    • Which modifiers have to appended to all therapy claims?
    • When does the KX modifier need to be added to the claim?
    • When do the CO/CQ modifiers need to be added to claims?

Other Assistive Personnel


ABNs


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