Billing and Coding: Physical Therapy - Home Health

• Social Security Act, Title XVIII, section 1834 (K)(5) incorporates the provisions in the Balanced Budget Act (BBA) of 1997; Section 4541 (a)(2) to require payment under a prospective payment system of outpatient rehabilitation services
• Social Security Act, Title XVIII, section 1835 (a)(C) establishes conditions for payment of claims to institutional providers of outpatient therapy services, including certification and plan of treatment requirements
• Social Security Act, Title XVIII, sections 1861(g)(p)(s)(u), and (cc)(ll) establish definitions for services, institutions, and other Medicare terms
• Social Security Act, Title XVIII, section 1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and medically necessary
• Social Security Act, Title XVIII, section 1862(a)(7) excludes routing physical examinations
• 42 Code of Federal Regulations (42CFR) Parts:
  
  • 409 includes the definition of 'reasonable and necessary' therapy services that applies to both Part A and Part B services
  • 411 describes those specific services excluded from Medicare or that are subject to limitations on payment
  • 420 describe specific Medicare program integrity requirements to prevent fraud and abuse. It also sets forth appeal rights of providers.
  • 421 identifies the activities required of the MACs that process Medicare claims
  • 424 describes the conditions for Medicare payment, including those governing Part B outpatient physical therapy services. In particular, it sets forth certification and plan of treatment requirements
  • 484 includes the personnel qualifications that Medicare requires for identification as a physical therapist or a physical therapy assistant
• Medicare General Information, Eligibility, and Entitlement Manual (Pub 100-01), Chapter 4, Section 30
• Medicare Benefit PolicyManual (Pub 100-02), Chapter 7, Sections 30.4, 40, and 40.2
• Medicare Claims Processing Manual (Pub 100-04), Chapter 10
• Medicare National Coverage Determinations (NCDs) Manual (Pub 100-03).
• CMS Manual System, Publication 100-08, Medicare Program Integrity, Transmittal 248, Change Request 5971, dated March 28, 2008.
• CMS Manual System, Publication 100-08, Medicare Program Integrity, Transmittal 63, Change Request 3010, dated January 23, 2004

For documentation requirements see the following reference: Medicare Benefit Policy Manual (Pub 100-02), Chapter 7, Section 40.2. Additional documentation requirements may be found under the appropriate CPT/HCPCS code, at: www.cms.hhs.gov . A recent update to the documentation requirements was published in the Federal Register on November 17, 2010 but has not yet been manualized. To view this update, please go to the home page for Home Health Prospective Payment System, select ‘Home Health Prospective Payment System Regulations and Notices’ and review Regulation Number CMSA 1510-F.

General Information
To qualify for the Medicare home health PPS benefit, under Sections 1814(a)(2)(C) and 1835(a)(2)(A), a Medicare beneficiary must meet the following requirements, which should be documented:

• Be confined to the home
• Under the care of a physician
• Receiving services under a plan of care established and periodically reviewed by a physician
• Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology, or have a continued need for occupational therapy

Physical Therapy Services
Skilled physical therapy services are reimbursable under Medicare if the services are documented as being:

• Ordered by a physician
• Provided by a skilled physical therapist, or under the general supervision of a skilled physical therapist
• Reasonable and necessary to the treatment of the illness or injury, or to the restoration or maintenance of function affected by the illness or injury
• Provided as a result of a valid, written, physician's signed and dated plan of treatment. The plan of treatment is established prior to the provision of physical therapy services and outlines the type, amount, frequency, and duration of the physical therapy services to be provided, identifies the functional diagnosis deficits, and anticipates the short and long term goals to be accomplished
• In accordance with the above guidelines as set forth in this LCD

Signature Requirements
Medicare requires a legible identity for services provided/ordered. The method used may be hand-written or electronic subject to state laws. The individual whose name is on the alternate signature method bears the responsibility for authenticity.

Treatment Notes

• Treatment notes should be completed per visit. They should be legible and clearly relate back to the established goals. Symbols, acronyms, and notation used in treatment notes should be:
  
  • Consistent with standard documentation
  • Discernable, either on their face (e.g. PT = Physical Therapy), or by supplied legends
  • Objective (e.g., 3/10 for pain)
• Treatment notes should readily reflect all services billed.
• Failure of treatment notes to meet the above may result in non-coverage.

This LCD should be interpreted to incorporate future changes in the ICD-10-CM or CPT/HCPCS coding systems such that its original intent and scope will not be substantively changed.

• Utilization Guidelines
  Throughout the LCD are stated utilization guidelines (i.e., number of visits), and DO NOT imply coverage or non-coverage of a service. Services must be reasonable and necessary for each individual and be supported by the plan of care and other documentation.
  
  
• Programs
  Medicare does not cover "packaged" or "constellation of predetermined" services (i.e., "programs"). Services must be individualized and reasonable and necessary for each beneficiary.
  
  
• Qualified Personnel
  Medicare does not pay for the services provided by aides/technicians regardless of the level of supervision. Medicare pays only for services delivered by qualified physical therapists and physical therapy assistants.