Medicare Compliance & Reimbursement

PTs need to show they delivered skilled therapy.

Therapists know that Medicare will reimburse for home PT services for those patients who meet the Centers for Medicare and Medicaid Services' homebound care and medically necessary services requirements - but they shouldn't expect bundles of cash when they only make one house call.

Typically the physician referral will say "home safety evaluation" because he or she suspects the patient has a problem getting around, says Fran Wheelock, director of program development in rehabilitation services, HealthReach Home Care and Hospice, Gardiner, ME.

PTs frequently get referrals for one-time evaluations from physician practices (rather than hospitals) and from insurance companies (especially managed care organizations) as a preventive care measure, notes Wheelock.

CMS guidelines indicate that if the PT makes only one visit (and there is no nursing or other rehab discipline involved), no reimbursement is made - "regardless of whether that one visit was truly skilled in nature and needed," explains Kenneth Babich, University Home Care Services Corporation, Columbus, OH. Advice: Know your own state's FI's interpretation of those regulations, recommends Robert Ford, manager of rehabilitation services for CareGroup Home Care of Belmont, MA. Ford says that his FI has determined that a one-time PT visit is reimbursable "if there is a skilled need and the PT delivers skilled therapy at that visit." Under those circumstances, "we are reimbursed at the partial episodic rate," he adds. LUPA Covers Two If the PT makes one visit and a nurse or another rehab professional also visits once, then Medicare will pay for those two total visits. Payment for these two visits falls under the low utilization payment adjustment (LUPA) reimbursement, says Babich, "but LUPA reimbursement is not very much and generally barely covers the actual company costs of the visits."

Assessment Drives Pay Regardless of the number of visits, comprehensive evaluation data is critical to payment. "OASIS data drives the reimbursement rate," says Babich. "Your assessment data should accurately reflect the patient's medical, clinical, and functional status," he notes.

Also, home health therapy employers are increasing requiring staff to be "visit conscientious," so you'll need to be able to justify your number of visits and why you're seeing particular patients, offers Babich. 

"The days of reckless abandon of unlimited therapy visits is a thing of the past," says Babich. Editor's Note: For more on CMS' homebound criteria, see Section 204.1 in the Medicare Carriers Manual. www.cms.hhs.gov/manuals.