Billing Part B Outpatient Therapy Services
Outpatient rehabilitation therapy includes Physical Therapy (PT), Occupational Therapy (OT), and Speech-Language Pathology (SLP) services. Medicare covers outpatient PT, OT, and SLP services when:
- A physician or Non-Physician Practitioner (NPP) certifies the “treatment plan,” called the Plan of Care (POC), ensuring:
- A patient needs therapy services
- POC is:
- Established by a physician, NPP, our qualified therapist provides services
- Reviewed periodically by a physician or NPP
- A patient gets services under physician care
- POC certifying the provider’s name and NPI is on the claim
- Providers meet medical necessity, documentation, and coding requirements
- CERT: Comprehensive Error Rate Testing
- A physician is a Doctor of Medicine, osteopathy, podiatric medicine, and optometry (only for low vision rehabilitation).
- NPP includes a Physician Assistant (PA), Clinical Nurse Specialist (CNS), or Nurse Practitioner (NP).
- A qualified Therapist includes a PT, OT, or SLP who meets regulatory qualifications as applicable, including state licensure or certification.
Common Outpatient Rehabilitation Therapy CERT Errors
- Missing certification and recertification(s): Physician’s, NPP’s, or therapist’s dated signature(s) approving the POC. Prevention: Confirm physician or NPP certified the POC (and recertified it when appropriate) with their signature and date.
- Missing signature: Physician, NPP, or therapist who developed the POC and established treatment plan date. Prevention: Ensure you add your dated signature and professional identification (for example, PT, OT).
- Missing or incomplete POC. Prevention: Create a complete POC that includes diagnoses, long-term goals, type, amount, frequency, and service(s) duration.
- Missing significant POC changes: Certifications and recertification(s). Prevention: Certify a significantly modified POC (physician or NPP signs and dates it).
- Missing total time: For timed procedures and total active treatment time. Prevention: Clearly document in 15-minute timed codes the total treatment time to support a number of units and codes billed for each treatment day; document total active treatment time (including timed and untimed codes) in the patient’s medical record.
- Missing or incomplete initial evaluation. Prevention: Document the initial evaluation with your signature, professional identification (for example, PT, OT), and the date you made the initial evaluation. For more information, refer to section 220.3 of the Medicare Benefit Policy Manual, Chapter 15.
- Missing or incomplete progress reports. Prevention: Progress reports justify the medical necessity and require information such as timing (at least once every 10 treatment days) and should include your signature, professional identification, and date. For more information, refer to section 220.3 of the Medicare Benefit Policy Manual, Chapter 15.
- Missing elements supporting medical necessity. Prevention: For more information, refer See sections 220 and 230 of the Medicare Benefit Policy Manual, Chapter 15.
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