June 21, 2023, Railroad Medicare's Outpatient Therapy Services Webcast: Documentation Requirements Questions and Answers

The following questions were received during our June 21, 2023, webinar.

Question 1: What should I do if I am unable to obtain the signature of a physician/NPP to certify a patient’s plan of care (POC)? 

Answer: If you cannot obtain a physician/NPP’s signature to certify a POC, you can provide proof of your attempts to obtain the provider’s signature. Supporting proof could be a fax receipt or a certified mail receipt. However, if no effort was made to obtain the certifying physicians/NPP’s signature, our Medical Review (MR) department is stating that they can verify a provider’s intent to certify a patient’s POC through other documentation within the patient’s medical record. Other methods used to certify a POC, an order or progress notes that supports the provider’s intent to order, for example, must contain the provider’s signature. The signature must be valid and notated within the last 90 days.

Question 2: If a patient refuses to perform physical therapy exercises/activities due to pain (or other reason), would this service be a billable?

Answer: If a patient refuses to perform physical therapy exercises/activities related to pain (or other reason) and these details are documented in the patient’s medical record, this would be a billable service. 

Addendum: Please note that a patient’s consistent refusal to participate in physical therapy exercises/activities should result in the patient being discharged from physical therapy services.

Question 3: Are providers required to submit an order for outpatient therapy services?

Answer: Although Medicare does not require providers to submit an order to render outpatient therapy services, when documentation is provided within the patient’s medical record, an order provides evidence that the patient both needs therapy services and is under the care of a physician. Certification requirements are met when a physician certifies the patient’s plan of care. However, if the provider’s signed order includes a valid plan of care, no further certification of the provider’s plan is required.

Question 4: What are examples of acceptable documents that can be used to certify a provider’s POC? 

Answer: Examples of acceptable certifying documents may be a:

• Physician’s progress note
• Physician/NPP order

or 

• Plan of care that is signed and dated by a physician/NPP

These documents must confirm that both the physician/NPP:

• Is aware that either outpatient therapy services are currently in progress or was in progress in the patient’s past

and 

• Lack any record of the provider disagreeing with the patient’s POC

Addendum: Other methods used to certify a POC, an order or progress notes that supports the provider’s intent to order, for example, must contain the provider’s signature. The signature must be valid and notated within the last 90 days.

Question 5: Are providers required to provide outpatient therapy treatment services on the same day as a patient’s initial evaluation?

Answer: Providers are not required to provide outpatient therapy treatment services on the same day as a patient’s initial evaluation. Different states have different regulations. Some providers are required to perform an evaluation prior to starting a patient’s course of outpatient therapy treatment services. 

Question 6: What is the duration/time limit of a valid POC?

Answer: The duration/time limit of a valid POC is 90 days. For a continuation of care to take place, the patient’s POC must be re-certified. 

Addendum: Outpatient therapy services cannot continue as a covered service if the patient current 90-day certification period ends and a newly dated POC is not certified. The Recertification process for a new POC can begin no more than 30 days prior to the end of the patient’s current certification period.

Question 7: In reference to the example provided in case study seven, how can a provider bill one unit when seven minutes is less than then eight minutes? 

Answer: Per Medicare’s guidelines, when counting units for therapy codes, one billable unit equals 15 minutes of rendered care, and as a rule of thumb any services provided for less than eight minutes are not considered as billable services. So consequently, in case study seven, neither CPT® code 97110, 97112 or 97410 could be billed separately to Railroad Medicare because each of these services were provided for less than seven minutes. 

However, the sum/total time spent rendering each of the CPT® services codes combined, equals a total of 21 minutes. Therefore, the provider could submit one billable unit to Medicare for payment. 

For further insight on the relationship between billable units and their correlating minutes, please refer to the table of reference that’s provided within this case study.

Question 8: Can Physical Therapy Assistants (PTAs) or Occupational Therapy Assistants (OTAs) sign a daily note or flowsheet without the co-signature of a physical therapist?

Answer: PTAs or OTAs can sign a daily note or flowsheet without the co-signature of a physical therapist. 

Question 9: Is the physical presence of a supervising therapist required when outpatient therapy services are rendered by their PTAs or OTAs?

Answer: The physical presence of a supervising therapist is not required when outpatient therapy services are rendered by a PTA or OTA. The qualified supervising therapist can be in another room, within the same office suite, or they can be offsite. Yet, the supervising therapist must be available to the PTA or OTA. 

Question 10: If a provider documents 120 minutes for one service code, how many units should the provider bill for this service code?

Answer: When counting units for therapy codes, one unit equals each 15-minute interval. So, if a provider documents 120 minutes for one 15-minute CPT® service code, he or she should bill a total of eight units. 

Question 11: I received multiple denials for outpatient therapy services after submitting my medical records. Why were my claims denied? 

Answer: During our webcast, we are not able to answer questions that are related to specific claims, due to privacy concerns.

For further assistance regarding these questions, please contact the Provider Contact Center of the Medicare Administrative Contractor (MAC) or the Specialty Medicare Administrative Contractor (SMAC) that your inquiry is related. The contact information for the Railroad Retirement Board SMAC’s provider contact center is 888–355–9165. 

Question 12: Our physical therapist received a denial after billing service CPT® code 97116. The denial stated that the service could not be separately billed, but I don’t understand why. Can you please clarify this denial for me? 

Answer: During our webcast, we are not able to answer questions that are related to specific claims, due to privacy concerns.

For further assistance regarding these questions, please contact the Provider Contact Center of the Medicare Administrative Contractor (MAC) or the Specialty Medicare Administrative Contractor (SMAC) that your inquiry is related. The contact information for the Railroad Retirement Board SMAC’s provider contact center is 888–355–9165. 

Question 13: If we have a patient that has multiple falls and injuries per year, what should we document to support that we are providing maintenance therapy for fall prevention? What should we do if we exceed the yearly therapy cap for PT services? 

Answer: Medical necessity is based on a patient’s diagnosis of an illness or a malformed body part. The provided therapy service would be based on the patient’s condition. It is important to know that fall prevention alone is not an approved condition for therapy treatment. The provider would support the patient’s need for therapy services by addressing the patient’s medical condition, and by documenting how therapy services is/has prevented a decline in the patient’s condition or how it has improved the patient’s condition. The services should also be of such a level of complexity and sophistication, or the condition of the patient shall be such, that the services required can be safely and effectively performed only by a person who must be, at least, a graduate of a program of training for PT services.

For details regarding the maintenance course of care for outpatient therapy services and medical necessity requirements for outpatient therapy services, please access the link below. 

Following your completion of the registration process on this page, the recording of the event will be available for you to view on demand.

Resource: Railroad Medicare’s Outpatient Therapy Services Webcast: General Coverage Guidelines. 

Question 14: Why was the maintenance course of care not addressed during this presentation?

Answer: This component of outpatient therapy services was addressed in our outpatient therapy webcast titled, “Railroad Medicare’s Outpatient Therapy Services Webcast: General Coverage Guidelines.” This first segment of our three-part series of outpatient therapy services webcast, was hosted on March 30, 2023. 

For details regarding the maintenance course of care for outpatient therapy services, please access the link below. Following your completion of the registration process on this page, the recording of the event will be available for you to view on demand.

Resource: Railroad Medicare’s Outpatient Therapy Services Webcast: General Coverage Guidelines. 

Question 15: I would link to share these events. Can you provide me with the registration links for each of your 0n-demand outpatient therapy webcast? 

Answer: The on-demand registration links for each series of our three-part outpatient therapy series webcast are as follows: 

• Railroad Medicare’s Outpatient Therapy Services Webcast: General Coverage Guidelines
• Railroad Medicare’s Outpatient Therapy Services Webcast: Top Medical Review Denials 
• Railroad Medicare’s Outpatient Therapy Services Webcast: Documentation Requirements 

Question 16: Will the certificate for today’s event have our names printed on them? 

Answer: Names are not prefilled on the certificate of attendance for today’s event. However, there is an area that's designated for you to write in your name on the certificate of attendance after the document is printed. 

Question 17: What is the course number for today’s webcast?

Answer: The course number for today's presentation is RRB4220874.