What Are the Key Guidelines for Medicare Physical Therapy Billing?
Have you ever felt frustrated trying to navigate the complex rules around Medicare physical therapy billing? As a physical therapist, you went through years of schooling to master the intricacies of the human body. But when it comes to getting properly reimbursed for your services, you’re faced with a whole different challenge. In this comprehensive guide, we’ll walk through the key guidelines step-by-step so you can bill Medicare with confidence. By the end, you’ll have the clarity and knowledge needed to avoid common mistakes and get your claims paid efficiently. Let’s get started!
Step 1: Verify the Patient’s Coverage
Before you can even think about Medicare physical therapy billing, you need to confirm the patient has active Medicare coverage. This may sound obvious, but it’s a step that’s easy to gloss over. When a patient first comes to you, take the extra minute to verify their coverage in Medicare’s system. This will save you major headaches down the road if it turns out the patient’s coverage is inactive. Nobody wants to complete treatment only to have claims rejected. So cover your bases upfront.
Step 2: Check the Therapy Cap
Now this part is crucial. You absolutely must check whether the patient has exceeded their annual therapy cap before providing services. This cap limits how much Medicare will pay for outpatient therapy per calendar year.
In 2023, the limit is $2,150 for physical therapy and speech language pathology services combined. Once the patient hits the cap, Medicare will not pay its share for additional services until the next year starts. Any expenses beyond the cap are fully the patient’s responsibility.
So before treating, confirm that the patient has not reached the limit. Otherwise, you risk not receiving reimbursement from Medicare and the patient will have to pay all out-of-pocket costs. Don’t let this happen: check the limit first.
Step 3: Get the Required Documentation
Medicare has strict rules about documentation needed to support your claims. Before Medicare physical therapy billing, make sure you have:
- A physician’s order for the services
- The initial evaluation report
- The plan of care established by the therapist
- Progress reports for each session
- The discharge summary when treatment concludes
Having complete documentation shows Medicare that the services were medically necessary. This will help ensure your claims aren’t denied for lack of information.
Step 4: Select the Right CPT Codes
Now comes the fun part: picking the CPT codes to represent the services provided. This is where understanding the nuances of Medicare coding is key.
Start by determining whether each service should be billed as:
- Therapeutic exercise
- Neuromuscular reeducation
- Therapeutic activities
- Self care management training
From there, select the most specific CPT code that describes the intervention performed. For example, don’t just default to 97110 (therapeutic exercise) if 97112 (neuromuscular reeducation) is more accurate. The clearer you are, the better.
Also be mindful of time-based codes. For any timed code, you can only bill one unit per session, regardless of how much time you spent. So choose carefully!
Step 5: Include the GPP and GO Modifiers
Here’s a big one: Medicare physical therapy billing requires extra billing modifiers to indicate whether an outpatient therapy service is subject to the therapy cap. Always include modifier GN, GO, or GP on claims, even if the patient hasn’t met their cap. This shows Medicare you checked the cap status and applied the mods appropriately.
GN means the service doesn’t apply to the cap. GO means it does apply, meaning the patient has not met the cap maximum. And GP means the cap has now been exceeded. Getting these modifiers wrong can lead to denied claims or allegations of fraud. So take care here.
Step 6: Submit Your Claim Correctly
You made it to the finish line: submitting your claim! Just a few last tips:
- Bill your claims electronically using the 837P HIPAA transaction. This avoids delays from mailing paper claims.
- Make sure your NPI and TIN are included and correct. These identify you as the billing provider.
- Include the rendering provider NPI if services were furnished by someone other than you.
- Use the proper place of service code based on where treatment occurred.
- Provide the ICD-10 diagnosis code to show medical necessity.
With attention to detail, your claims can sail smoothly through Medicare’s processing system.
Find Success, Avoid Pitfalls
And there you have it – following these key steps can help prevent the most common tripping points in Medicare physical therapy billing. No more banging your head against the wall when claims are rejected or denied.
You have the knowledge now to verify patient coverage, watch the therapy caps, document completely, choose the right codes, apply modifiers, and submit claims correctly. Medicare physical therapy billing doesn’t have to be impossibly complex.
FAQs
Yes, Medicare physical therapy billing allows you to bill for services provided by a PT assistant incident to your care. You must directly supervise the assistant and bill under your NPI as the rendering provider. Make sure to use the appropriate PT assistant modifier on the claim.
For small coding mistakes, you can submit an adjustment claim to fix the error instead of an entirely new claim. This is done using frequency code 7 to indicate a replacement or corrected claim.
No, you only need to check coverage at the very start of therapy. After initial verification, you can assume coverage remains active unless you receive an alert of a status change.
Unfortunately, Medicare considers those administrative tasks bundled into your overall services. You can only bill for direct treatment time spent with the patient.
Yes, Medicare covers medically necessary therapy provided in a patient’s home. Make sure to use the appropriate place of service code on the claim to indicate home services.
You have 1 full calendar year from the date of service to submit the initial claim to Medicare. After that point, the claim is considered late and may be denied.
Yes, Medicare Advantage plans must cover medically necessary therapy just like original Medicare. The Advantage plan is responsible for coverage instead of original Medicare.
Original Medicare does not require prior authorization for outpatient PT services. But Medicare Advantage plans can require pre-approval before starting therapy.
No, Medicare requires that providers maintain documentation to support all claims for at least 5 years. You cannot bill solely from memory if records are lost or destroyed.