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Home Health Outpatient Therapy

January 26, 2014 12 Comments

Home health outpatient therapy often conflicts with outpatient therapy financially, leaving providers to wonder how to figure out if a patient is in a home health plan of care.  There is a misperception on the rules of home health therapy and how it affects traditional outpatient therapy.  home health outpatient therapyLet’s take a look at the different aspects of home health:

  1. Home health provided under a home health plan of care and paid for by Medicare Part A
  2. Home health provided under a home health plan of care and paid for by Medicare Part B
  3. Home “outpatient therapy” paid for by Medicare Part B, provided by a home health agency or a private practice

Outpatient therapy clinics want to know if a patient is receiving home health therapy, more accurately put – is the beneficiary under a home health plan of care?  A patient may be referred to outpatient therapy, arrive at your clinic with a script for outpatient therapy and tell the admissions person that they are not receiving home health.  If a patient is under a home heath plan of care, outpatient therapy claims will be rejected for that time period.  How does this conflict happen?  Most often a patient is asked about home health physical therapy.  The patient will indicate they are not receiving physical therapy at home, and may also indicate if they had been recently discharged from physical therapy.  If the home health agency is still providing nursing services, then all eligible services must be provided through the home health agency.  Or alternatively all home health services have been completed but the home health agency has not sent a discharge notification to Medicare.

A home health plan of care can be indicated by #1 or #2 above.  In order to qualify for home health provided under Part A, the beneficiary must have had a recent 3 day hospitalization (inpatient, not observation), have Part A benefits, and have been discharged within 14 days from either the hospital or a skilled nursing facility in which the “individual was provided post-hospital extended care services.”  If the first home health visit is within 14 days of discharge, then financing is under the Part A benefit.  Once the Part A visits (100) are exhausted, medically necessary home health (under a home health plan of care) can continue under Part B.  Read up on home health coverage in the Medicare Benefits Policy Manual Chapter 7.

What is Home Health Outpatient Therapy

A new trend in home health outpatient therapy is burgeoning.  This is outpatient therapy where the therapist provides therapy in the beneficiary’s home.  Home health outpatient therapy refers to a home health agency providing outpatient therapy, billed to Part B, in the beneficiary’s home.  This therapy is not under a home health plan of care, but rather an outpatient therapy plan of care.  Reimbursement is per the Medicare Physician Fee Schedule, and no more reimbursement is given than that to the neighboring therapy clinic.  There is no adjustment, or charging for transportation to and from the home.  The trend is to provide therapy services in homes in geographically tight senior communities, independent living apartments and assisted living facilities.   Traditional outpatient clinics are expressing an interest in providing therapy in the home, but as outpatient therapy, not as a home health agency or under the home health benefit. We will have more information on this in a future post, but a brief discussion here was needed to contrast outpatient therapy in the home with home health therapy.

Are you getting a better understanding of the variances in the term “home health outpatient therapy” ?  Does this clear things up when you are looking at outpatient admission?  Or how about the curiosity you’ve had about providing traditional outpatient therapy in a patient’s home or residence?  How is your clinic verifying if the patient is currently under a home health plan of care that will preclude you getting outpatient therapy reimbursement?

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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Comments (12)

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  1. Hi Nancy, great article explaining the differences between Medicare Part A & B.
    It is very confusing even to MD’s that in home physical therapy services can be given to patients even if they are not homebound.
    We provide services to seniors throughout Long Island and Queens, NY.

  2. Hi Sajan, Thank you for your post. I received many email replies that detailed specific situations where therapy providers had their reimbursement denied, even after the patient stating they did not have “home health”. (either HHA did not D/C patient or patient was still receiving nursing services etc.) Most providers want to know a “fail safe” way of making sure the patient is no longer under HH plan of care. In areas of large Medicare population, therapists are looking to expand business for “home therapy” to independent/assisted communities!

  3. Thank you for your article on Home Health Outpatient Therapy. This has been an issue for us on several occasions, most recently this month, where Medicare denied at least one visit a patient had here in November. We are extremely diligent about making sure a Medicare patient has been discharged from home health services before beginning therapy at our facility. In fact, we always call the home health agency directly, rather than just asking the patient for a discharge date. In this case, the patient began therapy here in October but was later admitted to the hospital in early November because of a suspected blood clot. She wasn’t seen here for a couple of weeks and then returned to therapy. A nurse called to schedule a time to stop by the house to flush her PICC line. The agency was informed that she had returned to outpatient therapy and had to schedule the home visit around her PT appointments. The nurse never explained that the patient could not be seen in an outpatient setting while also being seen for a home health plan of care. Consequently, we were not informed that a nurse was coming to her home for one brief visit. The patient was seen in our clinic and Medicare is now taking back its payment.

    The patient’s family is very angry that the agency knew of the outpatient therapy but said nothing about Part B not paying for outpatient services when the patient is also in a home health episode. I know from experience that appealing Medicare’s decision to deny payment to us will not end favorably because Medicare feels we should have known the patient was in a home health episode. I’m not sure if that is always possible because when asked, the patients tell us they are not receiving services in the home. Many times they think this applies only to “home physical therapy.” I feel that if we should have known the patient was in a home health episode then the home health agency should have known the patient was receiving outpatient services. In this case, the agency did know about the outpatient PT but said nothing to us or the patient.

    I have now instructed my staff to educate all Medicare patients when they come in for an initial evaluation that our services will not be paid if someone is coming to their home or will come to their home, no matter the reason. I don’t feel it’s fair that small private practice clinics like ours should be penalized if the patient is seen for home services in the middle of an outpatient plan of care.

  4. Beata Zegarowski PT says:

    Hi,
    This is a great panel and I am also searching for answers ow to define outpatient Physical Therapy at home and home health Physical Therapy.

    I have been seen patients at their home under Medicare B for 3 years now. My referring MD has understood the explanation of the difference. Even though all physical therapists are going through the same schooling curriculum,
    Outpatient physical therapists are focused on specific goals pertaining specific muscle functions, balance disturbance or pain connected to loss of ROM. They use modalities to treat some of the dysfunctions for example an e stim and ultrasound. This is the course patients would take in an physical outpatient setting. The difference here is that patients will be seen at their home rather than the office. It takes time to travel there. It is basically one hour one patient ratio.
    Visits can last for several weeks to achieve well documented goal.

    Home health agencies have PT’s not necessarily trained in outpatient setting so they usually see patients post hospitalization. Average stay is to get people going and discharge to physical therapy. PT’s in these settings look for gross improvement in bed mobility, transfers and gait with a walker. They usually stay for 1-3 weeks.

    I understand that they can also bill under Med B. Personally I think that they should not be allowed to do that because the focus of home health PT is totally different as well as their training.

    Beata PT

  5. Lauren says:

    Can a patient be billed if they have home health & medicare denies their outpatient claim, or, does the office end up eating the charge? We did carry out our due diligence in asking the patient if he was having home health.

  6. Lauren – Thank you for your comment. Unfortunately you cannot bill the patient. Despite your efforts to inquire with the patient as to their current home health status, if the HHA has not closed the episode of care, outpatient therapy services will be denied as not covered. An ABN may not be issued in advance to pre-empt a denial due to a HH episode of care that has not been discharged. Many providers find that if they can determine that the patient had an episode of home health, they can contact the HHA to determine if the episode has been discharged. Keep in mind that even if PT or OT has been discharged from HH, that if the episode is still open due to other services being received, then therapy will still deny.

  7. Ashleigh says:

    Nancy,
    If a patient is receiving in home nursing, lets say for PICC line care or wound care, can we still bill Medicare if the patient is going to outpatient therapy.

  8. HI Ashleigh, and thank you for your question. Home health is subject to consolidated billing as note in the Home Health chapter in the Medicare Benefits Policy Manual. As such the HHA is responsible for all services while the beneficiary is under a PPS home health episode of care. Outpatient therapy would not be independently reimbursed (and if reimbursed, likely to be recouped). The HHA is welcome to contract with any OP therapy provider if they are not able to provide the services in the home.

  9. Maxine says:

    Good day Nancy,
    I recently got accredited as an ORF, it was a long tedious process (wish I was aware of you). I transitioned from a PTPP (PT in private practice). I have been in the PT field for 20 years, so I have a great working relationship with quite a few doctors, nurses and Home Health agencies. I’m aware that I can now bill for PT and OT in the home under Part B. Question: If a HH agency has discharged their pt from PT or OT Part A, as an ORF can I contract with them to continue these services under part B, if medically necessary? Using their therapists? If so, will you be able to assist in writing up contract?

  10. Shawna says:

    The beneficiary is still under the HHA episode of care. The outpatient PT clinic previously contracted with the HHA to provide the covered outpatient skilled services for __ # of sessions, which are now completed. No future gains to be had. The patient still wants to continue coming to the clinic for “wellness”, non-skilled therapy on the Lokomat with the Therapy Aide. The patient insists on a voluntary ABN and expects the clinic to bill Medicare with a GX/GY modifier. The reason given on the ABN that CMS may not pay the claim is “services are excluded under 1862(a)(1)of the SSA.” The family can begin upfront self payment (for “non skilled” services that CMS never covers anyway). Does anyone see a problem with this?

  11. Carol says:

    I am interested in making contact with any Home Healthcare agencies that are providing outpatient therapy under part B for non-home bound patients. I have read most of the material on the CMS website but I am still concerned about ensuring proper documentation for billing purposes. Thanks

  12. Carol, good luck in your quest to make contact with others. Many HHA do not do Medicare Part B within the agency, as the reimbursement is based upon the Medicare Physician’s Fee Schedule, and is lower that a HHA per visit rate. Many HHA that use contract therapists cannot afford to pay the same rates for OP as they do for HH Part A visits, henceforth they may not be included to offer Part B services. To answer the second part of your question, I recommend that you contact your HH Medicare Administration Contractor for their resources and references on Part B therapy services, claim type 034X. Also review the Medicare Benefits Policy Manual, Chapter 15, beginning at Section 220 for outpatient therapy documentation requirements, including functional limitation reporting.

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