Five Common Reimbursement Issues Facing Physical Therapists

Author: Paul Singh

Physical therapists should be aware that there are several common reimbursement issues that are outlined in the Coding and Payment Guide.  Listed below are 5 issues that physical therapists should take into consideration.

  1. All claims for outpatient rehabilitation, including specific audiology services and comprehensive outpatient rehabilitation facility (CORF) services, must be reported using a uniform coding system. This is mandated by a provision of the Balanced Budget Act (BBA). The coding system chosen by CMS were HCPCS Level I and II.
  2. Since the BBA also regulates a prospective payment system for these services, the Medicare physician fee schedule (MPFS) has become the method of payment for outpatient physical therapy services provided by the following:
    • Comprehensive outpatient rehabilitation facilities
    • Outpatient physical therapy providers (OPT)
    • Physical therapists in private practice (OPT)
    • Outpatient rehabilitation facilities (ORF, also called rehabilitation agencies)
    • Hospitals (when provided to outpatient and inpatients who are not in a covered Part A stay)
    • Skilled nursing facilities (when provided to residents not in a covered Part A stay and to nonresidents receiving outpatient rehabilitation services from the SNF)
    • Home health agencies (HHA) (for services provided to individuals who are not homebound or otherwise are not receiving services under a home health plan of care)
      NOTE: The MPFS is used as a method of payment for outpatient rehabilitation services furnished under arrangement with any of these providers. It is also used as the payment system for specific audiology and CORF services. Assignment is mandatory for CORFs.

  3. The MPFS is not applicable to outpatient rehabilitation services when provided by critical access hospitals (CAH), which are paid on a reasonable-cost basis.
  4. Facility rates are applicable to professional services performed in a facility other than the provider’s office while non-facility rates are applicable for services performed in the office.
  5. Payment for rehabilitation services provided to Part A inpatients of hospitals or SNFs is included in the respective prospective payment system (PPS) rate. Also for SNFs (but not hospitals), if the beneficiary has Part B, but not Part A coverage m(e.g. Part A benefits are exhausted), the SNF must bill the Part A contractor for any rehabilitation service (except audiologic function services).
    NOTE: Payment for rehabilitation services provided by home health agencies under a home health plan of care is included in the home health PPS rate.

Reimbursement issues can be confusing and lead to errors in billing.  StrataPT provides a unique billing solution that relieves you from the headaches and worries associated with billing issues.  In addition to our industry-leading billing, insurance credentialing and benefit verification services, StrataPT can also deliver a comprehensive blend of user-friendly scheduling, documentation and practice management software.

Contact one of our friendly team members today to learn more about how StrataPT can help take your practice to the next level.

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