Every industry has rules and regulations to prevent abuse, fraud, and waste, and Medicare is no option. Guidelines for Medicare and Medicaid providers for physical therapy billing include a segment on how much time you have to spend with a patient to be “bill worthy.”
Most of the people read or hear about rules like 8 minutes rule but unable to understand the definition of rules in this article you will not only get to know about physical therapy billing guidelines but also undergo through its functionality.
As a specialist in physical therapy, you have a lot to do — from treating patients and monitoring data on results to running a sustainable business to receiving fees for your services. Yeah, no wonder you’ve got less time than you would like to keep up with all the ins and outs of physical therapy billing.
For a physical therapist, it is necessary to have thorough information and all ins and outs of physical therapy billing. The following are the most important rules for physical therapy billing. Without wasting much time let’s jump on to the physical therapy billing guidelines.
One-on-One Services vs. Group Services
The way you pay for the amount of time you spend treating patients can vary; based on whether you offer one-on-one or community services. One-on-one service is an individual counseling program, as part of this program includes a patient in immediate, one-on-one contact.
Although community service often needs a continuous presence, there is no one-on-one interaction with each patient involved. As per the CMS, “This is a combined procedure for two or more than two patients who may or may not have the same behaviors.”
Getting credentialed by an insurance payer helps you to become an in-network physician that can help you access a wider base of potential customers, and support them. When you have not already earned a credential in your region with a big payer, you may want to try and change it. Some payers such as Medicare don’t authorize anonymous practitioners to pay or receive payment for any insured service.
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The 8-Minute Rule
The 8-Minute rule as known as “the eight rule” specifies how many support unit therapists will bill Medicare for the given service date. In order to obtain reimbursement from Medicare for a time-based code, you must have direct treatment for at least eight minutes, according to the law. However, although it sounds basic, there are some tricky 8-minute rule scenarios that could make you trip up.
If he or she is expected to pay a copayment through your patient’s policy, you can receive the payment when you offer your services. In most cases, waiving copayments or deductibles isn’t a good idea. There are however other avenues in which you can offer support to patients in need.
Learn your insurance policies carefully and find out more about what the payers deem appropriate when it comes to helping patients cover the costs of their care. If you still hit a dead end-handed, contact directly with your payers.
The American Occupational Therapy Association (AOTA), American Physical Therapy Association (APTA), and American Speech-Language-Hearing Association (ASHA), designed combined guidelines for Medicare Part A and Part B, which states that therapists should only co-treat a patient to have direct benefits to a patient.
If there are different therapists who give treatment to the same patient at the same time then what is the rule? Therapists who bill under Medicare Part B can’t bill separately for the same or multiple services offered to one patient at the same time.
On the other hand, therapists can bill separately if they are billed under Medicare part A, therapists should provide thorough treatment sessions and each therapist should be of different specialty and offer various treatments to the same patient at the same time.
To put it plainly, the time spent on a patient being treated is billable. There are a few complexities to bear in mind though. You cannot bill for:
- Unskilled preparation time
- Break times
- Multiple timed units because of different therapists
Under the following situation one should bill for a reevaluation (97002):
- You observe a major improvement, fall, or change in the condition of the patient, which was not expected in the plan of care (POC)
- If timely re-evaluation is necessary for your state practice act
- Change into the POC is required if the patient is unable to respond to the treatment given in the current POC
- You discover additional clinical findings in the course of treatment, which are somehow similar to the original treating condition
- You are treating a patient with a chronic condition, and you do not look at the patient occasionally
The Therapy Cap
The therapy cap was planned as a provisional solution to regulate Medicare costs and was announced as part of the Balanced Budget Act (BBA) of 1997. Despite a long-term force to cancel the cap, Congress lasted to renew the cap every year from its establishment. In 2018, the hard cap was canceled and substituted with a soft cap, which is known as the annual threshold amount. As a result of this, therapists keep track of the progress of their patients toward the threshold every year.
During the same treatment period, if you offer two distinct services you may require to apply Modifier 59 to inform that payment should be done separately for both services.
This modifier is a part of the automatic therapy cap exceptions process. If the patient is reached the therapy cap to continue treatment and you think it is medically required for the patient then your reasons for continuing therapy can be documented by attaching KX modifier.
If you declare an ABN because you think that specific services are not reasonable and medically required, then the GA modifier should be incorporated into the claim to indicate that you have an ABN on file.
Patients should sign an Advance Beneficiary Notice of Noncoverage (ABN) in order to offer Medicare patients services that they consider are not covered by Medicare or not required medically. This means that the patient will bear the financial cost of treatment if claims are declined by Medicare.