Outpatient Therapy and Home Health Services at Same Time
I receive many questions regarding coverage of outpatient therapy services by the Medicare program when the Medicare beneficiary is also receiving home health services. In this article, I will answer 7 of the more frequently asked questions I receive.
Question
Does the Medicare program pay for outpatient therapy services at the same time the Medicare beneficiary is receiving home health services?
Answer
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Question
If a Medicare beneficiary is receiving physical therapy and/or occupational therapy under an open home health episode of care and also requires speech therapy, but the home health agency does not provide speech therapy, will the Medicare program pay for outpatient speech therapy at the same time the Medicare beneficiary is receiving physical therapy and/or occupational therapy under an open home health episode of care?
Answer
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Question
How can I be paid by the home health agency (HHA) if I provide outpatient therapy services while the Medicare beneficiary is also receiving home health services under their Part A benefits?
Answer
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Question
What are my options if the home health agency (HHA) won’t enter into a contractual arrangement with me to provide outpatient therapy services to the Medicare beneficiary?
Answer
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Question
If I issue an advance beneficiary notice of noncoverage (ABN) to the Medicare beneficiary and they select Option #1 in Section G, what do I do?
Answer[restrict paid=true]
If the Medicare beneficiary selects Option #1 in Section G, you will be required to submit the claim to your Medicare Administrative Contractor (MAC). All CPT codes submitted on the claim would require the discipline specific modifier (GN, GO, GP) as well as the GA modifier be appended to them. The GA modifier will notify your MAC that you expect the Medicare program to deny the services and you have had the Medicare beneficiary sign a valid ABN. This will cause your MAC to deny the services and shift financial responsibility to the Medicare beneficiary. You can charge what you want for the service(s) you provided and are not limited to the Medicare Physician Fee Schedule allowed amount for each CPT code.[/mepr-show]
Question
If I issue an advance beneficiary notice of noncoverage (ABN) to the Medicare beneficiary and they select Option #2 in Section G, what do I do?
Answer
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Question
I provided outpatient therapy services to a Medicare beneficiary and was paid for my services by my Medicare Administrative Contractor (MAC). A few weeks later, I received a letter from my MAC informing me that the Medicare beneficiary was receiving home health services during the same time frame I saw them for outpatient therapy and the MAC is now requesting I refund the payments I received for those visits. What are my options?
Answer
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Question
To be proactive, can I issue an ABN to every Medicare beneficiary prior to the initiation of outpatient therapy services?
Answer
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Question
Are there any exceptions where the Medicare program would pay for outpatient therapy services while the Medicare beneficiary is receiving home health services during the same time period?
Answer
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All material posted on our website is the intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be used, reproduced, or posted as your own material without the prior written approval of Gawenda Seminars & Consulting, Inc.
This article is not intended to and does not serve as legal advice or as consultative services, but is for general information purposes only.
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In regards to biling outpt PT, we have a pt who resides in an ALF and was referred to us for outpt PT for strengthening. Upon completion of the PT eval, the pt says that they are also recieving vestibular rehab at a free standing outpt clinic. Are we still able to bill our PT eval?
If you are asking if a patient can have the same discipline of therapy at 2 different locations, CMS does not prevent that from occurring.
Rick,
What about a situation in which a patient is receiving home health services however gets an outpatient PT referral for something such as lymphedema management or pelvic floor therapy that is unable to be offered by a home health agency? Any exceptions?
No, there are no exceptions.
What about specialized services (97755 – wheelchair evaluation, 97760 – orthotic evaluation)?
No, there are no exceptions.
Or other specialized outpatient services, such as a modified barium swallow study?
Please read the last Q&A in the article. That answers applies to everything.
Please advise on this scenario: A patient is receiving HH physical therapy but has other needs (ie, lymphedema rx) that is not provided by the HH agency. An ABN is issued and the Medicare recipient pays privately as described above and the claim is submitted as in option 1. HH discharges the patient a week or so later so now the outpatient services are covered. Will the charges be denied since our initial claim with the GA modifier indicates they are not covered? I’m just wondering how long it takes the system to show that they are no longer under a HH plan of care. Thanks so much!
I can’t answer how long it takes to update the system. It will also depend on when the HHA closes out the case.
Can a PT from an outpatient physical therapy clinic who is already enrolled CMS provide care in the home without changes to enrollment rather than in the clinic?
Are you billing the OP visit in the home through the group private practice? If yes, then yes. You would change the POS from an 11 to a 12.
Do Medicare replacement policies (such as Medicare United Health Care, Medicare Humana, Medicare Wellcare, etc) pay for outpatient therapy services at the same time the beneficiary is receiving home health services?
You would need to check with the specific MA plan.
There is no answer listed for what happens if a patient selects option 2 on the ABN, Assuming at that point you can enter into any payment arrangement agreed upon?
Thank you! There was a coding issue. It has not been corrected.
Do you know of any options in a case where the patient is discharged from all Home Health services say on 10/12/22 but Medicare still shows the discharge date as of 10/22/22, for us to get paid for our services? The patient clearly is not receiving Home Health anymore but the Home Health Company did not submit the proper paperwork to Medicare.
You would need to contact the HHA and have them correct the DC date if the date is incorrect.
If a patient is receiving HH services from VA (not under Part A), could that patient also receive outpatient services since the HH service is not paid for by Medicare?
You would need to check with the VA.
The IPTCA recently sent out some forms to use for patients who may be enrolled in Home Health. Have you seen these? They indicate that they can be used if the patient has had home health services within the last 6 months. That is ideal for us because the biggest risk we take is a patient who has indicated they are discharged, which is backed up by the HHA, but then then patient returns to HHA concurrently with outpatient Physical Therapy or the HHA does not abide by the discharge they provided us and there is crossover that Medicare recoups. My concern is that to my knowledge CMs will not abide by any forms like this that is not an ABN, and that we could only issue an ABN if we confirmed they are still enrolled in HHA and we submit the modifiers. I know this only makes sense if you have seen the forms, but do these forms allow us to bill the patient if we Medicare recoups due to home health?
I have not seen the forms but only a correctly and properly completed and executed ABN can transfer financial liability to the patient.
That is what we thought. And just to confirm, we can only issue that ABN when we have confirmed there is an open HHA episode? For example, we could not issue an ABN if an episode recently ended and there is only a chance they will go into a new episode?
I recommend you read Section 50 of the link below.
https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c30.pdf
If I’m seeing a knee OA patient pre-operatively, would I bill an evaluation or re-evaluation for their first post-op visit IF the patient received home health PT immediately after surgery (so home health sandwiched in the middle of outpatient PT)?
That is for you to determine.