Home Health Services and Outpatient Therapy Simultaneously
A question I often receive is does the Medicare program pay for a Medicare beneficiary to receive outpatient therapy services while they are simultaneously receiving home health services under an open home health agency (HHA) plan of care? In this article, I will answer this question plus provide resources for the outpatient therapy provider to determine if the Medicare beneficiary is receiving home health services.
The answer is
The content here is for members only log in here or sign up.
Can you define “Outpatient Therapy Services”? I understand this may sound like a basic question however some OP services are not subject to the same perspective payment system of HH is my understanding.
On claims submitted by providers using the institutional claim format, CWF enforces consolidated billing for outpatient therapies by recognizing as therapies all services billed under revenue codes 042x, 043x, 044x. These revenue codes are subject to consolidated billing when submitted on types of bill 013x, 023x, 034x, 074x, 075x or 085x. Consolidated billing edits do not apply on TOB 034x when the HHA is billing for disposable negative pressure wound therapy services during a HH episode.
On claims submitted by practitioners using the professional claim format, CWF enforces consolidated billing for outpatient therapies using a list of HCPCS codes which represent therapy services.
Are there any exceptions for a specialized service like powered wheelchair evaluation or a modified barium swallow study?
No!
What if a patient is receiving Home Health IV treatments only and the Physician orders OP Aquatic PT – can the patient attend aquatic therapy in this scenario?
No!
If outpatient therapy is seeing a patient, say for several weeks and then the pt is opened up by a HHA, does therapy have priority so to speak or does the HHA get reimbursed from that point forward and not the outpatient therapy.
The home health agency takes priority.
Do Medicare replacement plans also apply in this situation or only straight Medicare?
The article is written on for traditional Medicare. You would have to check with the specific Medicare Advantage plan to see if they pay for outpatient therapy services at the same time the patient is receiving home health services.
We have Medicare asking for refunds on patients that we treated while not knowing the patient was in HH at the time of treatment. Prior to scheduling a patient for an evaluation in our office we ask the patient if they are in Home Health and we verify on the MAC portal that there is no HHEH indicated. We have printed out confirmation from the MAC portal that no HH eligibility is on file for the date of treatment in our office. After receiving the letter from Medicare requesting a refund I phoned our MAC and was told that the MAC portal was not updated until 3 months after we treated the patient. My appeal was denied even though we verified the patient’s eligibility based on Medicare’s information. How do you suggest we proceed? How can we stop this from happening in the future when the MAC portal is not current?
HI Tim,
I wish there was a reply to your question so I am posting this to create activity.
Can a patient receive outpatient services; i.e. nursing, physical, occupational or speech, and have HH services at the same time as long as they are on different days?
No
My assistant contacted the HHA who is providing PT in the home. I am an OT providing Lymphedema tx. The director said that because they have no one to provide the Lymphedema tx that Medicare would pay.
Medicare will not pay for outpatient therapy at the same time the patient is receiving home health services. You would have to contract with the HHA and have them pay you or have the patient sign an ABN and then the patient would be responsible to pay you for your services.
Thank you. Can you offer the “address” in the MC manual? The closest thing I found was 230.6 Therapy Services Furnished Under Arrangements with Providers and Clinics
B. Special Rules for Hospitals
I’m in private practice. The director was quite rude stating she’s been in the “business” for 30 yrs and she knows what she’s talking about. I’d like to be able to cite the reference.
This makes me want to have all my MC patients sign an ABN…lol
You can read the HHA Billing Manual at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c10.pdf
what happens if a HH client needs a modified barium swallow study or FEES study how is that handled when in homehealth sevices?
The hospital would have to get a contract with the HHA.