What is Outpatient Therapy at Home?
Outpatient Therapy at Home differs from therapy services that are part of an episode of care for home health. Under the Patient-Driven Groupings Model, all home health therapy is billed together (PDGM). Instead of the PDGM, the Medicare Physician’s Fee Schedule is utilised to price outpatient therapy (MPFS). Ultimately, patients do not have to meet the Outpatient Therapy at Home status.
The Outpatient Therapy at Home agency will be reimbursed 80% of the authorized amount using the MPFS. Patient or additional insurance pays the remaining 20%.
Coverage Guidelines
Claim forms are submitted under Medicare Part A, while Medicare Part B is responsible for paying approved claims. So, the patient must have Part A and Part B of Medicare.
Part B of Medicare pays for outpatient PT, OT, and SLP services if they are:
- Given to a Medicare recipient who has Part B of the program
- Provided by a doctor who certifies that the services are medically necessary
- reasonable and necessary to treat the illness or injury, or to restore or keep the function affected by the illness or injury, and provided under a written plan of care (POC)
Before starting Outpatient Therapy at Home, Medicare requires that the therapist do a thorough evaluation of the patient and that the therapist sign all progress notes. In addition, Medicare’s rules say that the plan of care must include all of the following:
- Diagnosis
- The methods or procedures used to treat each Outpatient Therapy at Home
- Goals that make sense
- The kind, amount, frequency, and length of each form of treatment
- Rehab potential
Billing Requirements of Outpatient Therapy at Home
A provider pays for Outpatient Therapy at Home to a beneficiary only if they meet certain requirements. The following are the rules:
- The person needed services because he or she needed therapy services.
- A physician/NPP sets up and reviews a strategy for giving Outpatient Therapies at Home.
- The person was under a doctor’s care when during Outpatient Therapy at Home
- When a doctor or NPP validates an outpatient therapy plan, they confirm the aforementioned three requirements. Certified claims are paid.
- Claims for outpatient PT, OT, and SLP services must include the National Provider Identifier (NPI) of the certifying physician for a PT, OT, or SLP care plan.
- Outpatient PT, OT, and SLP claims need functional reporting.
- Functional limits mentioned on a claim must fit the patient’s therapeutic plan of care and long-term goals.
- The provider must write down the number of minutes billed for each code (as opposed to home health billing, in which providers bill for each visit).
- Every 10 visits or before the 30th of the month, make a progress report (whichever is first).
- The provider must write every treatment done.
- PTAs and COTAs can do work, but they need supervision.
- The bill type to use on a UB-04 is 34X.
- Rev codes and home health are the same.
Recommendations
- Check the patient’s eligibility in the common working file to ensure they are not in the middle of a home health episode. Remember that even if a patient is no longer getting home health services, the agency must still discharge and close the episode of care or outpatient therapy services denied as not covered.
- Check your eligibility and benefits every time. Medicare benefits have limits, so make sure your staff is aware of them and knows the important details.
- Therapists should ask patients if they’re receiving or have recently received home health care.
- Medicare does not require an order, but when written down in the patient’s medical record, it shows that the patient needs therapy services and is under a doctor’s care.
- Most services covered have copayments, so it’s important to have a way to collect them. Receiving payments ahead makes bad debt less likely.
- Copays will create more work and bills, so teach your staff how to deal with this.
