Most outpatient physical therapists are aware that the Centers for Medicare and Medicaid (CMS) cover physical therapy as a benefit for people with Medicare. Often the question that arises is exactly what are the requirements for patients to receive physical therapy care? This post will describe the basic criteria that patients need to meet for Medicare to cover the care.Before we start, it’s important to remember that Medicare is a health insurance company. Like all health care insurers, it has specific rules to follow to receive payment. Let’s explore those rules.
In order to provide physical therapy care to Medicare beneficiaries, the outpatient practice must be enrolled in Medicare. Private practice PT’s are considered suppliers while hospital clinics, rehab agencies and CORF’s are considered providers. PT’s working in a private practice setting must also be enrolled individually with Medicare using their NPI number in order to bill Medicare for services. Any PT’s working in hospitals, rehab agencies or a Comprehensive Outpatient Rehabilitation Facilities (CORF’s) do not have to enroll individually as the billing is done through the organization. It’s critical to be clear if you are not participating with Medicare or that you cannot treat Medicare patients no matter how you bill. Patients with Medicare may only be treated by participating clinicians.
The first and most critical rule is that the patient’s condition must meet the definition of medical necessity. Specifically, the care must be justifiably reasonable and necessary. Note there are two parts to this definition – reasonable and necessary. Meeting the medical necessity definition is required both to initiate care as well as to justify ongoing care. Justification is done through documentation, so you must be clear in showing your care is reasonable and necessary.The other major requirement is the need for the condition of the patient is as such that it requires skilled care.Let’s look at each of these in detail.
First, Medicare defines reasonable care as that which is based on current evidence. It also means that the specific interventions provided for a particular condition be appropriate according to the evidence and acceptable medical standards. Furthermore, the intensity, frequency and duration of the care must also fit appropriately for the condition. Understandably this is a little vague, but it gives clinicians flexibility to use their judgment based on the patient’s needs. For example, Medicare would most likely find the use of balance training exercises as an intervention not reasonable for a patient who scores well on any balance outcome tests. They would argue the patient’s high balance test scores do not indicate, based on the evidence, that this patient would benefit from this intervention.
For the care to be necessary, the patient’s condition must be severe/complex enough to require treatment. There is a reasonable expectation that the condition will improve or is improving as a result of physical therapy care. To clarify the improvement requirement, it does not mean the patient must be improving in order to receive benefits. CMS revised that rule in 2013 to reflect this means the patient must need skilled services (more on this below) in order to continue.Necessary care also means the patient cannot have achieved maximum improvement, and there’s the expectation that the patient will achieve the desired outcome in a predictable and reasonable time frame. Once again, this is also a little vague, but it allows the physician to their judgment in an effort to meet the patient’s needs. Again, your documentation must clearly demonstrate this.Treatment to return to high-level activities like golf, tennis, running or even work is not considered as medically necessary, even if that’s the patient’s previous functional baseline.
The second criteria are the patient’s condition must be complex enough to require the skills and knowledge of a physical therapist or a supervised physical therapist assistant. If the patient’s condition does not satisfy this requirement Medicare deems this as not meeting the medical necessity requirement.Frequently there is confusion on exactly what this means. In some cases, it’s clear and easy to demonstrate the complexity of the patient’s problem, in others, it’s less obvious.Let’s look at a case of a patient’s 8 weeks post TKA who is walking with minimal to no limp and has recovered 80% of their strength. Medicare would not consider this patient complex enough to need skilled services. They would argue this patient only needs to get stronger and this could be done independently.Likewise, Medicare does not consider patients with cognitive dysfunction or those needing to be guided through their home exercise program as being complex enough to meet the skilled care requirement. In this case, they would note that guiding a patient could be done by a caregiver and does not need the knowledge and skills of a physical therapist.In short, if the therapist does not need to spend direct one-to-one time with the patient during treatment, they may not be meeting the skilled services requirement.
Medicare designates who can provide physical therapy to its beneficiaries. Provision of these services must fall within their scope of practice as determined by state and local laws.The following can provide physical therapy and bill Medicare for it:
Furthermore, they also clearly note who cannot provide billable Medicare services. PT aides, rehab technicians, athletic trainers, massage therapists, exercise physiologists, recreation therapists, kinesiotherapists, pilates instructors and life skills trainers are not considered qualified to provide physical therapy services to patients with Medicare. CMS is about ensuring that safe care is provided for Medicare beneficiaries. They believe only those trained in physical therapy, such as physical therapists or PTA’s, possess the necessary skills to provide effective and appropriate care to this population. If one has not been trained in physical therapy, then they are not qualified to manage Medicare patients.Clinically this means if you are providing therapy to a patient with Medicare and you designate some of the patient’s exercise program to be carried out by a PT aide, athletic trainer or exercise physiologist, you may not bill Medicare for it as it’s not considered a covered service.You could certainly argue that physicians, APRN’s or PA’s receive no training in physical therapy either. However, these are the current Medicare regulations.
Medicare also designates which settings patients can be in when receiving Part B services. These include the following:
In all cases, these are considered outpatient visits. In the case of the patients in a SNF long term care unit, typically these are residents of the SNF and have exhausted or are no longer eligible for SNF Part A coverage. Note this does not include inpatients in an acute care hospital, an inpatient rehab facility or an acute rehab hospital who are all covered under Medicare Part A.One area of coverage that is often confusing are patients under “observation status” in an acute care hospital. All services for these patients are covered under Part B because the hospital has not admitted them. This makes them outpatients and the hospital has 3 days to decide whether to admit them or send them home.
It’s important to recognize the other type of insurance coverage a Medicare beneficiary might utilize. Medicare Advantage Plans (MA) are insurance plans provided by private commercial insurance companies like Aetna, United Healthcare, Anthem Blue Cross or Humana to name a few. These plans provide coverage that includes the benefits found in traditional Medicare Part A and B. They almost all also provide drug coverage benefit and many will also provide vision and dental coverage as well.To see and bill for patients enrolled in an MA plan you must be a participating provider for that insurance company. Your contract dictates your payment levels and you must follow that payer’s rules and guidelines for that patient’s plan. In many cases, these plans require pre-authorization and tightly control the number of visits and frequently the amount they will pay per visit.
Maintenance care is a covered benefit under Medicare. However, there still seems to be confusion. As mentioned above, since the Jimmo v Sebillius ruling in 2014, there no longer is an improvement standard requirement. You may provide care that either maintains a particular functional level or prevents/slows further deterioration of the patient’s functional abilities. The caveat here is the provision of the maintenance program must be complex enough that it requires the skills and knowledge of a physical therapist. Just overseeing the patient’s exercise program does not qualify.Should you ever be questioned justification through your documentation is critical. Specifically, your notes need to clearly reflect the patient’s needs, the risks of not providing maintenance care and how this program requires the skills of a physical therapist.
Understanding how and when Medicare provides for physical therapy services can help you decide if you wish to participate with Medicare and, if so, the requirements that you need to meet.
The PT EMR platform built on automation.
