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You should know: Medicare covers OUTPATIENT PHYSICAL THERAPY services IN HOME under Part B

Before you read on

This article is NOT guidance that you should offer home visits but rather just explores Medicare’s home visit reimbursement program under Part B. Only you can decide that for your practice after considering all of the different aspects, not all of which are covered here at all or super in-depth. We are not lawyers, insurance agents, infectious disease specialists, etc, or anything like that.

Medicare Part B Coverage for Home Health PT

Most outpatient physical therapists think about home health services rehab as happening to patients prior coming into their clinic. However, Medicare patients are eligible for coverage of home health rehab services provided by private practices in the patient’s home as well. Medicare defines a “home” in the normal sense of an house, condo or apartment but also as any institution other than a hospital, Critical Access Hospital or SNF.

During challenging times, every option should be considered for the benefit of the patient and for the practice. Providing care in patient’s homes has it’s own challenges and benefits.

In this article we will explore eligibility requirements and the processes to see a patient and get paid by Medicare B. In this challenging pandemic period this may be an avenue for some patients to continue to receive rehabilitation care.

Eligibility

Eligibility requirements are the same for both Part A and Part B coverage. The primary difference is Part A covers the patient when they’ve had either at least 3 days as an inpatient in the hospital or a stay at a SNF. Part B covers any other patients who meet the criteria for home care.

According to Medicare regulations, patient may receive home care services if they are considered homebound and need skilled care. Home bound means the patient must have difficulty getting out of their house. Their doctor must certify that they are indeed homebound. Medicare considers skilled care as defined by the PT’s state practice act.

Like the requirements for coverage of outpatient rehab, the patient must be under the care of a physician. Also the physical therapy services provided must be under the plan of care from either the physician or the PT and signed off by the doctor.

Additionally, similar to outpatient care Medicare requires the following:

  • The patient’s physician must certify that the services being provided are specific, safe and effective for that patient’s condition.
  • The amount, frequency and duration of the care must be reasonable and appropriate.
  • The patient’s problem must be of such complexity that it requires the skills of a physical therapist.
  • Lastly, it is expected that the patient’s condition will improve in a reasonable time frame or require the skills of a therapist to either design or carry out a maintenance program.

What does homebound mean?

If a practice is considering seeing patients in their home instead of the clinic then you must be sure the patient meets the definition of homebound.

According to Medicare patients must meet the following criteria to be considered homebound:

Criterion One:

The patient must either: - due to their illness or injury, need to use crutches, canes, wheelchairs, and walkers; or special transportation; or the assistance of another person in order to leave their place of residence.

OR

Has a condition where leaving his or her home is medically contraindicated.

AND

Criterion Two:

There must exist a normal inability to leave home

AND ADDITIONALLY

Leaving home must require a considerable and taxing effort.

Process

To initiate home care rehab services the therapist would need a physician referral (which demonstrates the patient is under their care). The referral must specify the services being requested and the frequency they are to be provided (e.g., Physical Therapy 2x/week).

Like the plan of care requirements for outpatient care, there must be a plan of care (POC) signed by the physician. This plan of care must contain the same documentation as the normal outpatient POC does.

Treatment and documentation requirements are the same as when treated in the office other than a re-evaluation must be done every 30 days not every 10 visits. This re-evaluation is similar to the progress report done in outpatient care. The therapist should show progression towards the goals and justification of the need for ongoing home care rehab services.

Billing

Billing is completed on the 1500 form using the same coding as in the clinic. The fee schedule is the same Medicare Physician Fee schedule as used in all outpatient care. The only difference is the location of the service must be designated as “Home-Location other than a hospital or other facility where patient receives care in a private residence”.

Some IMPORTANT BASIC Considerations in light of COVID-19

In these very extraordinary times seeing patients in their homes may be viable option for many outpatient therapy practices. Just bear in mind some important considerations as you look at the potential of providing care this way. They include but are not limited to:

Patient Health and Safety
Staff Health and Safety
Liability
Operations

Many patients may not be interested in having therapists come to their home due to the potential exposure to COVID-19. This would be clearly true if they are trying to practice social distancing. The same would be true for your employees. Their risk is increased since they have no control over the cleanliness or who is in the patient’s house.

Not unlike treating in the practice, therapist’s doing home care are on company time so any injuries or issues, including car accidents, fall under workers compensation. Be sure your worker comp and liability insurances will cover you for this activity.

During this challenging time it may be necessary for a practice to consider seeing some patients in their home.

These are not all the considerations but some of them.

The Bottom Line

Many PTs may not think of outpatient treatment as something that can happen in a patient’s home but that isn’t the case. Medicare has allowed for in-home treatment on an outpatient basis for quite some time. With some important considerations, it may be something that your PT practice could consider.

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