Institutional Outpatient Therapy Claims Being Denied

April 28, 2023
Rick Gawenda

Institutional outpatient therapy providers are experiencing claims being denied by their Medicare Administrative Contractor (MAC) beginning on and after April 1, 2023 for claims received by the MAC. In this article, I will answer the following questions:

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      1. Rick, I understand to you this is a simple answer. To me and most likely the rest of your subscribers it makes no sense. “If billing on a UB-04 claim form, yes” I don’t know what hospital based OP PT clinics billing form is.

        Please answer in a way that I can gain some information from this. Do most hospital based OP PT clinic bill on a UB-04? Is it common or is it uncommon?

        I want to know how this is going to impact me, yes I know you don’t know my specific location and all the information, but you can tell me what to generally expect.

        Does this mean that I should expect to be able to market to hospital based physicians for their Medicare referrals as they will no longer be able to send them to their hospital OP PT clinics without the claims being denied?

        1. If a PT, OT or SLP practices in a hospital outpatient therapy setting and they are responsible for the department, they know if they submit claims on a UB-04 claim form or a 1500-claim form. If they do not, then that would be a huge concern.

          Depending on how the therapy department is established and/or where it’s located will determine which claim form they submit claims on. This article has nothing to do with the ability for physicians to refer to any setting or an opportunity for private practice PTs to market to physicians. If you are a private practice, this does not impact you. If you contract therapists to hospitals, this could impact you.

  1. We put the Rendering Provider’s NPI in the Attending Physician field on our UB04 for Physical/Occupational Therapy. Now that we have to put the Referring Physician in the “Attending Physician” field as they are the provider overseeing patient care, where are we supposed to put the Rendering Provider NPI now? I called CMS and no one could assist me with this question. All she could tell me is that “they are working on it”. Is Rendering Provider information not required on a UB04 for physical or occupational therapists?. Thank you in advance.

  2. I have the same question as Cheryl. Can you help with this? With Stark laws, I’m not understanding how we can bill this way and keep things separate

    1. Stark law has nothing to do reggarding identifying the attending the physician on the UB-04 claim form.

  3. Rick,

    Thank you for this information. The MLN Matters was quite confusing. Thank you for breaking the information down.