Physical therapists often submit claims to Medicare in order to receive reimbursement for services provided to Medicare beneficiaries. Yet in a report written by the Department of Health and Human Services’ Office of Inspector General (OIG), 61% of Medicare claims for outpatient physical therapy reviewed by OIG were non-compliant. In this blog, we’ll give you some tips for submitting clean claims to ensure proper submission and timely payment.

Please note that in 2023, Original Medicare covers up to $2,230 for PT and SLP before requiring the provider to indicate that the services provided to clients are medically necessary.

How to Start Accepting Medicare Part B

If you want to start accepting clients covered by Medicare Part B, follow these steps:

 

• • Familiarize yourself with the enrollment process, including terminology used by Medicare and the information required to enroll.

• • Get a National Provider Identifier (NPI) number. Medicare uses this unique identifier to process claims.

• • Log in to the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) using your NPI.

• • Fill out, review, and submit an application. If your application is accepted, you’ll receive a Certification Statement.

• • Please note that the Certification Statement must be signed and dated with blue ink. Once filled, mail it to a designated Medicare contractor (don’t forget to include any supporting documents requested) within 15 days of your electronic submission.

Additionally, please note that your effective date of filing is the date the Medicare contractors receive the Certification Statement, not the mailing date.

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How to Submit Medicare Claims

Verify Patient Eligibility and Benefits.

Before providing services, check that your client is eligible for Medicare and that the service is covered by Medicare. Use an EMR like Fusion, which allows you to create a client questionnaire to determine eligibility, track verifications, and verify eligibility. By incorporating eligibility checks in your daily workflow, you’re less likely to miss coverage problems.

Complete Appropriate Documentation.

This includes the client’s medical record and other necessary documents, such as a current plan of care and physician referrals.

This is another time when your EMR can be helpful, especially with features like alerts for missing notes or signatures.

Submit Claims Electronically.

Physical therapists are required to submit claims electronically through Medicare’s electronic submission system. This can be done through a billing service or directly through Medicare.

Follow Up on Claims.

After submitting a claim, physical therapists should be proactive in following up with Medicare to ensure timely payment. This may involve contacting Medicare directly or working with a billing service to resolve any payment or denial issues.

Your EMR should include a way to check claims status quickly and efficiently.

It is important for physical therapists to understand the billing and reimbursement process for Medicare in order to minimize errors, ensure proper payment, and provide high-quality care to Medicare beneficiaries.

Avoid These Mistakes:

According to the DHHS OIG review, these were the most common mistakes found in claims.

Services Were Not Medically Necessary:

The service must be reasonable, necessary, safe, effective, and meet accepted medical standards while fulfilling the client’s medical needs.

For outpatient physical therapy services to be considered reasonable and necessary, they must meet the quoted conditions, be deemed a specific and effective treatment, and require the expertise of a therapist or their supervision.

Basically, you need to justify the cost of services because they improve client outcomes or that the client would worsen if these services were not provided.

Coding Did Not Meet Medicare Requirements

Use the proper coding. Physical therapists should use Current Procedural Terminology (CPT) codes for the services provided as well as appropriate modifiers to indicate any special circumstances.

To avoid coding mistakes, you should have at least one AMA license to access codes. Ideally, your EMR should integrate an AMA license (usually for a fee) so you can access the codes as you’re creating claims.

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Services Were Not Reasonable

The amount, frequency, and duration of the physical therapy services were not reasonable and consistent with standards of practice.

You need to prove that the services require the skills of a therapist and that they contribute to improving client outcomes.

Documentation Did Not Meet Medicare Requirements

 

• • Physical therapy services must follow a written plan established before treatment begins.

• • The treatment plan must include the type, amount, frequency, duration, diagnosis, and anticipated goals of the physical therapy services to be provided.

• • The goals should be relevant to the functional impairments diagnosed and be measurable.

• • The treatment plan must include the creator’s signature, professional credentials, and the date it was established.

• • The plan of care must be recertified when a significant modification of the plan is needed or at least every 90 days after initial treatment.

• • Therapists must create and maintain a treatment note for each treatment day and each service provided. The treatment note must include:

1.  The date of treatment

2. Each specific service provided and billed,

3. The total treatment minutes for timed codes and total minutes for the entire therapy session

4. The signature and professional identification of the therapist who provided or supervised the service

Error	Prevention
Missing certification and recertification(s): Physician’s, NPP’s, or therapist’s dated signatures(s) approving the POC	Confirm physician or NPP certified the POC (and recertified it when appropriate) with their signature and date
Missing signature: Physician, NPP, or therapist who developed the POC and established treatment plan date	Ensure you add your dated signature and professional identification (for example, PT, OT)
Missing or incomplete POC	Create a complete POC that includes diagnoses, long-term goals, type, amount, frequency, and service(s) duration
Missing significant POC changes: Certifications and recertification(s)	Certify a significantly modified POC (physician of NPP signs and dates it)
Missing total time: For times procedures and total active treatment time	Clearly document in 15-minute timed codes the total treatment time to support a number of units and codes billed for each treatment day; document total active treatment time (including timed and untimed codes) in the patient’s medical records
Missing or incomplete initial evaluation	Document initial evaluation with your signature, professional identification (for example, PT, OT) and date you made the initial evaluation (see section 220.3 of Medicare Benefit Policy Manual, Chapter 15 for more information)
Missing or incomplete progress reports	Progress reports justify medical necessity and require information such as timing (at least once every 10 treatment days) and should include your signature, professional identification, and date (see section 220.3 of Medicare Benefit Policy Manual, Chapter 15 for more information)
Missing elements supporting medical necessity	See sections 220 and 230 of Medicare Benefit Policy Manual, Chapter 15 for more information

No Expectation of Significant Improvement

Evidence (which may include the plan of care, progress reports, and notes) failed to provide an expectation of improvement significant enough to justify the claim or further services.

You need to use your documentation to prove your services led to significant improvement worth the cost of the services and the need for additional services.

As a physical therapist, navigating the strict requirements of Medicare can be challenging. However, by proactively staying informed about these requirements and integrating thorough reviews and verifications into your daily workflow, you can prevent errors and demonstrate that your services should be reimbursed.

Fusion eliminates the headache of documentation, billing, and compliance. Our workflow is crafted to save you time and streamline your work, with built-in verification and error checks to make your life a breeze. Don’t take our word for it. Schedule a demo today.