If you’re a licensed occupational therapist (OT) enrolled through CMS, you probably treat Medicare patients. Medicare covers millions of adults age 65 and older, as well as many younger individuals with disabilities—a significant patient population for rehab services like occupational therapy.
Don’t let the intricacies of Medicare billing get in the way of helping patients regain independence and improve their quality of life! Let’s review how Medicare billing and occupational therapy (OT) work together to keep your practice running smoothly.
Occupational Therapy Services Covered By Medicare
Let’s focus on Medicare Part B, which covers outpatient care like OT. Evaluations, assessments, and treatments aimed at rehabilitating or improving function in activities of daily living (ADLs), mobility, and cognition are covered under Medicare Part B. This includes interventions for strokes, arthritis, and Parkinson’s disease. Medicare also covers OT services focused on safety concerns like fall prevention as well as recommendations for assistive technology.
All services must be medically necessary to be reimbursed by Medicare. This means your documentation needs to clearly demonstrate how the service or therapy was needed to diagnose or treat a patient’s illness or injury. Medicare has spending limits for outpatient therapy, but continued care can be justified if needed. All eligible treatments must be billed to Medicare, ensuring patients receive the benefits entitled to them.
OT Services Not Covered by Medicare
Not all OT services qualify for Medicare coverage. Therapy not deemed essential for recovery, maintenance programs focused on education, services beyond approved guidelines, and preventive or wellness programs are all services Medicare doesn’t cover.
Additionally, services provided by occupational therapy assistants (OTAs) might require supervision by a licensed OT in addition to being billed with a modifier to be covered. Think ergonomic assessments for healthy office workers, treatment for handwriting difficulties solely for improved penmanship, or if a patient wants help with home modifications solely for convenience. In these cases, you must provide the patient with an Advance Beneficiary Notice (ABN) before rendering services.
Providing an Advance Beneficiary Notice (ABN)
An ABN is a form that notifies the patient they may be required to pay for a service if Medicare doesn’t cover it. It helps patients decide whether to proceed with non-covered services and how much they may have to pay out-of-pocket, protecting them from surprise medical bills. The American Occupational Therapy Association (AOTA) provides detailed guidelines on issuing ABNs.
Medicare and Occupational Therapy Billing Best Practices
Ensuring proper billing for Medicare-covered OT services requires attention to detail. Regarding Medicare billing and occupational therapy, here are some key areas to focus on:
1. Documentation Do’s and Don’ts
Do clearly and thoroughly document:
- the patient’s medical diagnosis, functional impairments, treatment goals, and progress.
- all services or treatments provided and a plan of care.
- medical necessity and justification for each service.
- time spent on one-on-one, face-to-face care (especially for timed-based treatments).
Don’t make these mistakes:
- relying on vague language or therapy lingo.
- omitting crucial details or fail to update records regularly.
- altering documentation to inflate services or outcomes.
2. Code Correct: ICD-10, HCPCS, and CPT Codes
Medicare uses these coding systems for OT claims:
- ICD-10 Codes: diagnosis codes that accurately reflect the patient’s condition and justify the need for OT services
- CPT Codes: codes for OT procedures and interventions performed, including evaluation and management (E/M) codes, which ensure accuracy and specificity.
- HCPCS Codes: billing codes for durable medical equipment (DME) or supplies provided to the patient
3. Avoid Common Billing Pitfalls
When billing Medicare for outpatient therapy services, you should avoid these common billing errors:
- Upcoding or using unspecified codes. Codes should align with the documented service and diagnosis.
- Surpassing the therapy threshold. If a claim will exceed the annual spending limit, justification with the KX modifier is required (see below).
- Not knowing how to bill for individual vs. group therapy. Understand the differences and document participation details for group sessions.
- Unbundling, or billing separately for a service or procedure that should be bundled with others.
- Failing to demonstrate medical necessity through proper documentation.
- Failing to obtain prior authorization for services or procedures that require pre-approval.
Additional tips to prevent claim denials:
- Stay updated on Medicare coding and billing guidelines in addition to coverage policies. This ensures compliance and avoids billing errors or audits.
- Remember that changes occur regularly, so consult the Centers for Medicare & Medicaid Services (CMS) website for the latest information.
- Don’t forget the 8-minute rule for timed-based billing units!
Modifiers and Medicare Reimbursements
Beyond standard codes, Medicare utilizes modifiers to convey additional information on claims. Here’s how some key modifiers impact OT service reimbursements:
KX Modifier and the OT Service Threshold
Medicare sets annual payment thresholds for outpatient therapy services—meaning there’s a maximum amount they will pay for those types of services annually per beneficiary. In 2023, the payment threshold or spending limit for OT was $2,230. Once that amount is exceeded, the KX modifier must be added to the patient’s claims, and any additional therapy must be justified in the accompanying documentation. Adding the KX modifier conveys that the therapist believes continued treatment is medically necessary.
Using Modifiers for Telehealth Services
Telehealth services have become increasingly common in healthcare. Specific modifiers like GT, GQ, or 95 may be needed when billing Medicare, depending on the type of telehealth service provided, as well as how the patient and provider communicated.
Working with Assistants, Techs, and Students
If occupational therapy assistants (OTAs), technicians, or students are involved in patient care, specific modifiers must be added to reflect their role and the level of supervision a licensed OT provided. For instance, if an OTA performs more than 10% of a service or treatment, add a CO modifier to the claim.
The Importance of Medicare Billing for OT
Because Medicare is a federal health insurance program, it reimburses providers at lower rates than private health insurers. With that in mind, in addition to the significant number of Medicare patients you will likely see in your therapy clinic, it’s critical to bill these claims correctly—ensuring you get paid.
So, by understanding how to code, bill, and document Medicare claims correctly, you’ll avoid denials. Remember that technology like specialized billing software can be your ally—leading to less hassle, fewer denied claims, and quicker payments. Let technology lighten your billing load so you can focus on exceptional patient care.