Ask the Contractor
Teleconference
January 24, 2006
Topic:
Physical Therapy/Occupational Therapy
Questions & Answers
Question 1
Does Medicare require a face to face visit with the referring physician every
30 days?
Answer 1: Medicare regulations do not
require a physician/non-physician practitioner to see a patient for Physical
Therapy/Occupational Therapy payment.
However a physician may require that their patient be seen before they
will certify or re-certify a plan of care.
The plan of care must be certified or re-certified every 30 days.
Question 2:
Does a patient need an original referral from their attending physician
before physical therapy can begin?
Answer 2: According
to CH 15 Section 220.1.1 Physicians order is recommended but not required for
payment. The order simply provides evidence of both the need for care and that
the patient is under the care of a physician. However, the certification
requirements are met when the physician certifies the plan of care.
Question 3:
How is the referring physician documented on the 1500 claim form?
Answer 3:
The referring physician’s name & UPIN number are supplied in item 17
& 17a.
Question 4:
Are there any plans to remove the 2006 physical therapy cap?
Answer 4: NHIC has not received
communication from CMS indicating the removal of caps.
Question 5: What should a physical therapist
do if they disagree with the 2006 physical therapy cap implemented by CMS?
Answer 5:
Voice your concerns to your association.
Question 6:
If physical therapy started in 2005 and went on into 2006, will the 2006
physical therapy cap still apply?
Answer 6: Yes, beginning with therapy
services provided on dates of service from 01/01/06.
Question 7:
Can physical therapy and occupational therapy be done at the same
location? Will this affect the 2006
physical therapy cap?
Answer 7: PT & OT may be done at the
same location. There is one cap for
physical therapy and speech language pathology combined, and a separate cap for
occupational therapy. They will not
affect each other if performed at the same location.
Question 8:
Is the 2006 physical therapy cap for each injury or for the entire year?
Answer 8: The cap is for the entire year,
regardless of injury. After the Ask the
Contractor Teleconference, CMS issued Change Request 4364. Please follow this link to find more
information on the exception process:
http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4364.pdf
Question 9:
Our office has older claims from 2005 as well as claims for 2006 that
have not been billed yet. Is it okay to
bill the 2006 claims while we work on work on the older claims?
Answer 9:
Yes, the cap only applies to 2006 dates of service and you may bill the
2006 claims first. Please be aware that
we are currently accepting claims from dates of service 10/01/2004 and
after. However payment on claims within
this time frame but are older than a year will be reduced by 10%.
Question 10:
Has there been any changes with requirements for the physical therapy
modifiers?
Answer 10: No. The requirements for GN, GO & GP are
still the same as last year.
Question 11:
Does home health physical therapy count towards the cap?
Answer 11: No, home health is covered under
Medicare Part A. The financial cap only
applies to outpatient physical or occupational therapy services.
Question 12:
If a patient is in a home health, is there a way to check for that
information with Medicare before we see the patient?
Answer 12:
Yes, you may contact customer service for that information. Consolidated billing applies; Customer
Service can tell you if a patient is under a Home Health Episode of care for
specific dates of service.
Question 13:
What should we do if the service is a non-covered service by Medicare?
Answer 13: You may bill the patient your
normal charge for non-covered services up-front. If the patient has another insurance that may
cover the service, you would bill the claim to Medicare with a GY
modifier.
Question 14:
What if the patient has a prescription for a non-covered service?
Answer 14:
It is still non-covered. For
example, if the doctor writes a prescription for Pilates for medical reasons,
it will still be non-covered by Medicare since Pilates are never covered by the
Medicare program.
Question 15:
What was the form for exclusions from Medicare benefits? Where may I find it?
Answer 15:
The form is CMS 20007, Notice of Exclusion from Medicare Benefits. It
can be located at the following website: http://new.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf
Question 16:
Is there any way for a patient to appeal claims that are denied because
the 2006 physical therapy cap has been met?
Answer 16: A patient may appeal the
Medicare denial. However, the limitation
is statutory and at this time Medicare will not pay a claim after the limit is
reached based on the beneficiaries need for the service.
Question 17:
Is the 97002 covered by Medicare for the year of 2006?
Answer 17:
Yes as long as it is a medical necessity. However, the Correct Coding Initiative may
apply if billed with other PT services on the same day.
Question 18: If a patient went to physical
therapy in 2004 and came back in 2006 (there is almost least a 5 to 6 month
gap), what guidelines are there to establish a new patient for physical
therapy?
Answer 18:
A new plan of care would be required.
Question 19:
How can we accurately determine how many visits the 2006 physical
therapy cap allows a patient?
Answer 19:
Using the Medicare Physical Fee Schedule for your locality, find the CPT
codes you would bill for the plan of care for the patient and determine how
many would be allotted until the $1740 cap is reached. The Interactive Voice Response (IVR) system
will also provide how much has been applied to the therapy cap.
Question 20:
How are patients made aware that they have exceeded the 2006 physical
therapy cap?
Answer 20:
The limit and the amount applied to their limit will be printed on their
Medicare Summary Notice. The patient can
call 1-800-Medicare to find out how much has been applied to the therapy caps.
Question 21: Will there be any impact to the
hospital based physical therapy?
Answer 21:
Hospitals may experience an impact if patients continue their therapy
after the cap at an outpatient hospital.
Question 22:
If congress changes the 4.4% reduction on the 2006 fee schedule which
may happen in February, will NHIC Medicare be ready to implement it?
Answer 22:
The fee schedule has been
updated; NHIC is currently processing claims to pay at the updated fee schedule
amount. There is no penalty to providers
who choose not to bill the patient for the difference in co-insurance
amounts. NHIC has until July to process
claims.
Question 23:
Are the active management wound cares applied to the physical therapy
cap?
Answer 23:
Yes, there is a list on the CMS website that indicates what codes are
subject to the limits. Some of the wound
care codes are subjected to the physical therapy cap when they are performed by
a physical therapist.
Question 24:
I heard something about congress working on an over cap to assist
patients who go over their physical therapy cap such as stroke patients. Could I have more information on that?
Answer 24:
At this time there is no assistance to patients for additional payments
to physical therapy services once the physical therapy cap has been met. There may be something in the works, but as
the rules stand now, there is no other option once the cap has been met.
Information released in February of 2006 indicates there are
exceptions to the caps. Please follow
this website to review:
http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1782
Question 25:
Since $1740 is the allowed amount, Medicare will only pay $1392 (80%),
is that correct?
Answer 25:
Yes, for Medicare covered therapy services. The patient is responsible for the
co-insurance and deductible amounts.
Question 26:
Is there additional information on the IVR regarding the 2006 physical
therapy cap?
Answer 26:
The amounts applied to the therapy caps are given on the Interactive
Voice Response system.
Question 27:
Should we still use item 19?
Answer 27:
For claims processed in
For claims processed in the
Question 28:
When claims deny for having met the cap, will the Medicare Summary
Notice indicate patient responsibility?
Answer 28:
The Medicare Summary Notice will indicate the patient’s
responsibility.
Question 29:
Do you have any information about if secondary payers will be covering
physical therapy once the 2006 physical therapy cap has been met?
Answer 29:
We have no information on that.
You would need to contact each secondary insurance
and verify through them if they will pick up once the cap has been met.
Question 30:
How do we charge a Medicare patient once the cap has been met?
Answer 30:
You may charge them your normal rate for the service rendered once the
2006 physical therapy cap has been met.
Question 31:
With CPT code 97150, if a PT assistant is supervising 2 patients doing therapy
at the same time, is that the correct code to use?
Answer 31:
Yes, CPT 97150 represents, Therapeutic procedure(s),
group, 2 or more individuals.
Question 32:
Is morbid obesity covered for physical therapy?
Answer 32:
No, morbid obesity as a diagnosis code is not covered, although symptoms
caused by the morbid obesity may be covered if it is a medical necessity.
Question 33:
Is there software to access how much of the physical therapy cap has
been met?
Answer 33:
NHIC is currently conducting a pilot program that allows for this type
of information and additional information to be accessed on line. At this time it is still a pilot
project. If it goes national, additional
information will be forthcoming.
Question 34:
If a patient walks in without a referral, can they be seen for physical
therapy?
Answer 34:
A patient may self referral themselves, but a physician would still need
to review & sign off on the plan of care.
3/2/2006