Medicare ADVISOR Q&A

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Pauline Watts and Danna Mullins
New Year's Resolutions
Published Jan. 20, 2003

With our first Medicare Advisor column of 2003, we would like to provide you with three resolutions to help assure a more prosperous New Year for your organization.
1. Read your site of service manual. Medicare has a service manual for all providers of care to Medicare beneficiaries. These manuals are provided for skilled nursing facilities, home health agencies, outpatient physical therapy and comprehensive outpatient rehabilitation facilities, and hospitals (which includes inpatient rehabilitation facilities). These manuals should be available in your facility. In addition, the Centers for Medicare and Medicaid Services (CMS) has made it easy to obtain them via their Website (cms.hhs.gov/manuals/cmstoc.asp). Chapter 2 of each manual relates to coverage of services.
2. Understand the difference in regulations for Medicare Part A and Part B services. The regulations concerning Part A and Part B therapy services are becoming more distinct as CMS continues to define and clarify the regulations relating to these services. Part A and Part B cover rehab services differently with regard to eligibility and reimbursement. The regulations for Part A services have been clearly explained in the Final Rule for PPS (for each site of service) and are found in the Federal Register (www.access.gpo.gov/su_docs/aces/aces140.html). Part B regulations are continually updated through the memoranda to Medicare's fiscal intermediaries (FI) and carriers. Although the FIs and carriers are responsible for disseminating this information to the providers, delays do occur. CMS has this information available at cms.hhs.gov/manuals/memos/comm_date_dsc.asp.
3. Get to know your local medical review policies (LMRP). Medicare is a federal program that is administered through contractors. Although the rules and regulations for Medicare are defined by the federal government through the CMS, each individual contractor (FI or carrier) develops their own policies for compliance. These are known as local medical review policies, and identify the circumstances under which particular items or services will be or will not be covered. Depending on the contractor, these policies can be highly detailed or provide only basic instruction. These policies usually contain four elements: benefit category, statutory exclusion, medical necessity and coding. Generally, the LMRP can be accessed through the contractors' Websites.

ATCs and Medicare
Published Feb. 17, 2003
Question: In what capacity are certified athletic trainers allowed to work with Medicare patients? Is pool therapy by athletic trainers allowed if under the direction of a PT?
Answer: The Code of Federal Regulations (CFR) names only physical therapists and physical therapy assistants as personnel qualified to deliver Medicare reimbursable physical therapy services. While athletic trainers, exercise physiologists, massage therapists, and kinesiologists have additional training beyond that of a physical therapy aide or technician, they are not considered as qualified physical therapy personnel by Medicare. Regardless of training, any rehab staff that are not physical therapists or physical therapy assistants should be considered physical therapy aides under Medicare regulations. Given that Medicare Part B does not reimburse for aide time, athletic trainers are not allowed to perform pool therapy that is billed to Medicare.

What Constitutes a 'Home Visit?'
Published March 17, 2003
Question: A home health agency has informed me that if I go to a patient's house and the patient is not there, I am to leave a note for the patient to call me. When the patient calls me, I am to discuss with the patient his home exercise program and whatever else pertains to the patient's plan of care. After doing this, the agency says I am allowed to document care and would not have a missed visit. Is this allowed by Medicare?
Answer: No. According to the information found in Code of Federal Regulation Subpart E - Home Health Services Under Hospital Insurance § 409.48 Visits (c) definition of visit: "A visit is an episode of personal contact with the beneficiary by staff of the HHA or others under arrangement with the HHA, for the purpose of providing a covered service. (1) Generally, one visit may be covered each time a HHA employee or someone providing home health services under arrangement enters the beneficiary's home and provides a covered service to a beneficiary who meets the criteria of §409.42 (confined to the home, under the care of a physician, in need of skilled services and under a plan of care)."
To bill Medicare for a visit, there must be direct contact with the beneficiary in the home with the provision of skilled intervention/procedure. It is prudent to document all contact with the patient. However, the telephone contact and review of the home program does not meet the definition of a visit or qualify as a skilled service. Therefore, the visit cannot be billed and the visit is documented as a missed visit or is rescheduled for the same week.

Covering Massage
Published April 28, 2003
Question: Is massage a covered service under Medicare? Will Medicare cover it if a massage therapist does it? Does it have to be done by a PT? If Medicare does cover it, would you bill Part A or Part B?
Answer: Yes, Medicare does cover massage as part of a physical therapy plan of treatment. Whether it is billed under Part A or Part B depends upon the coverage being provided. Under Part A, massage is reimbursed through the per diem rate for the RUG-III category under which the patient is receiving care. For Part A, massage can be performed by either the physical therapist or the physical therapist assistant. Under Part A, in principle, massage could be performed by an aide who is a licensed massage therapist; however, the massage therapist would have to be employed as a therapy aide AND be in the direct line of sight of the supervising physical therapist (assistants can not supervise aides and bill for the aides' time under Medicare rules). This scenario would probably be rarely feasible considering patient privacy issues. Under Part B, Medicare pays for the services of a licensed physical therapist or physical therapist assistant under the general supervision of a physical therapist when under a physical therapy plan of treatment. The services of supportive personnel cannot be billed under the direct one-on-one modalities or procedures, including massage. A licensed massage therapist cannot provide direct one-on-one treatment that is billed to Medicare Part B. Use code 97124 for massage that is billed to Medicare Part B.

Exceptions to the "In Room" Ruling
Published May 26, 2003
Question: We have two small clinics in a rural area. Are there any exceptions to the "in room" ruling in rural areas when a PT is supervising a PTA with Medicare patients? We would like for one of our assistants to see the patients in our smaller clinic but they are mostly Medicare patients.
Answer: The rule you are referring applies to a physical therapist in independent practice. Under this category of provider licensing, Medicare requires that the therapist provide personal supervision of both therapists and therapist assistants working under their provider number. There are no exceptions to this rule. If your Medicare provider approval is for an outpatient physical therapy clinic, then this rule does not apply for Medicare participation. Medicare, however, defines supervision of a therapist assistant as "general supervision with periodic observation of the actual activity." Noncompliance with this regulation can result in substantial penalties for the provider. Therefore, for Medicare, it will be necessary to have a therapist attend and supervise treatment sessions at a level appropriate to need to comply with this regulation. We are concerned with your comment that "It is not efficient for us to send a PT over there." Provision of physical therapy services should be at a level appropriate to the patient need and not simply for productivity or maximizing reimbursement. Medicare regulations, as identified in the Code of Federal Regulations, require that the practitioner provide the appropriate level of qualified staff to provide the necessary level of care. You must also follow your state practice act in terms of delegation and supervision of therapist assistants. These regulations can be more restrictive than the Medicare reimbursement requirements and certainly must be followed.

Rehab Maintenance: Who Pays?
Published June 23, 2003
Question: Frequently patients who have entered the maintenance phase in their rehabilitation insist on continuing to see me and insist that I bill Medicare for it. I explain the difference between acute rehab and maintenance and that Medicare does not consider maintenance therapy medically necessary and will not pay for it. Their reply is always something like, "I'm afraid I will get worse if I don't continue." I want them to feel that I'm advocating for them, but at the same time, I am very mindful of not abusing the Medicare system. I have these patients sign a form that states clearly that they understand that Medicare may deny future reimbursement and that they would be responsible for payment. These patients insist that I continue to send their MD letters requesting new referrals. I am reluctant to do this as it puts the MD in a difficult position asking them to repeatedly order maintenance PT. Any thoughts on how I can handle this situation?
Answer: Medicare has regulations for this situation. You should have the patient sign the Advanced Beneficiary Notice (ABN) and bill Medicare under the demand bill code. By signing the ABN, the patient acknowledges that, if Medicare does not cover the services, they will be responsible for them. You are correct in telling them that the services they are requesting are considered maintenance and that Medicare will not cover them. They have the right to ask you to submit a demand bill to Medicare. When the bill is denied and you receive the Explanation of Benefits (EOB), they can submit the bill under an alternative insurance policy that may or may not cover the services or pay you directly. There is nothing unethical or wrong about what they are asking you to do. As long as you are informing them that, under the Medicare guidelines, the services are considered maintenance therapy and therefore are not covered, there is no reason that these patients should not pay privately for your services. You must charge the same rate as you would if Medicare was paying the bill, (i.e., the physician fee schedule rate for the appropriate CPT code), for which the patient is 100 percent responsible.


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What are the regulations for physical therapy aides working with patients in critical access hospital beds, long term care Medicare Part B, and outpatient within hospital setting?

carolyn ainsley,  physical therapist,  critical access hospital/LTCAugust 16, 2010
Honokaa, HI



I am trying to find out rules and regulations for Physical Therapist Asisstants working with Medicare pts. I have heard that a PT has to be present in the clinic for PTA's to beable to work with medicare pts and want to know if this is true. I would appreciate if you could tell me how I can find this out along with any other rules that apply with PTA's. Thanks for your time. Deanna

Deanna Latham,  PTAApril 29, 2009
Omak, WA




     

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