I often receive questions when a Medicare beneficiary exceeds the therapy cap that go something like this: Currently, I have a patient that has gone over the $2010 or $3000 amount for Medicare. She has not progressed and responded to therapy interventions. She insists that her secondary will pick up the full amount if Medicare denies. I’ve used the GA modifier basically telling Medicare the therapy services are not necessary and had the patient sign an advance beneficiary notice of noncoverage (ABN) form. Will the secondary pay if the Medicare program denies? Does it matter if the secondary insurance is

On December 12, 2017, President Trump signed the National Defense Authorization Act (NDAA) into law. One important piece of legislation included in the NDAA directs the Department of Defense (DOD) to add physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) to the TRICARE program as an eligible provider of therapy services. Even though the NDAA is now law, the DOD must now make the change to add PTAs and OTAs as eligible providers of therapy services. The DOD must also establish, in regulations, requirements for the supervision of PTAs and OTAs. Until this is completed, PTAs and OTAs are

The Centers for Medicare and Medicaid Services (CMS) has published a 5-minute video that explains the Targeted Probe and Educate (TPE) program in more detail. To view the TPE video, click HERE. To read a more detailed article I wrote on the TPE program, click HERE.

Therapists and assistants often spend time with patients, a parent of a patient, or a patient’s caregiver such as a spouse, son, daughter or a hired caregiver teaching them exercises to do at home as part of a home exercise program. In addition, therapists and assistants spend time training a patient’s caregiver (i.e. parent, spouse, son, daughter) how to assist the patient with various activities outside of the clinic setting such as gait on level services, ascending/descending steps with an assistive device, dressing, bathing, bed mobility, transfers, feeding and using a speech generating communication device. Two questions I receive concerning

Palmetto GBA has posted an online module that provides an overview of Change of Therapy (COT) in the Skilled Nursing Facility (SNF) setting. The following topics are introduced in this course: coverage, regulations, Resource Utilization Group (RUG), SNF Prospective Payment System (PPS), assessments, and tips. To access the module, click HERE.

The Centers for Medicare and Medicaid Services (CMS) has issued instructions for Medicare Administrative Contractors (MACs) to provide notification of the reopening process and to notify the provider or supplier of their intent to reopen a specific claim when requested documentation is received after a denial of the claim has been made. If the MACs receive the requested information from a provider or supplier after a denial has been issued but within a reasonable number of days (generally 15 calendar days after the denial date), they have the discretion to reopen the claim. MACs who choose to reopen a specific

Whether an insurance carrier will pay for therapy services provided in the patient’s home under their outpatient therapy benefits is the answer most people do not like; it is insurance carrier specific. Regarding the Medicare program, the Centers for Medicare and Medicaid Services (CMS) states therapy services are payable under the Medicare Physician Fee Schedule when furnished by a provider or supplier in the following settings:

Last week, I published “Who Writes Progress Reports Under Medicare Part B” and as you can imagine, had lots of follow up questions and comments. Some of the questions received were: 1. Can a physical therapist assistant (PTA) or occupational therapy assistant (OTA) see the Medicare patient the same day the physical therapist (PT) or occupational therapist (OT) also sees the patient and will write the progress report? 2. Can a PTA or OTA see the Medicare beneficiary for a follow-up therapy visit, collect the subjective information and objective data and include that information in their daily note? 3. Can