(Medicare Benefit Policy Manual)

 When a hospital sends its therapists to the home of an individual who is registered as an outpatient of the hospital but who is unable, for medical reasons, to come to the hospital to receive medically necessary therapy services, the services must meet the requirements applicable to outpatient hospital therapy services, as set forth in the regulations and applicable Medicare manuals.  The hospital may bill for those services directly using bill type 13X or 85X for critical access hospitals.    If a hospital sends its therapists to provide therapy services to individuals who are registered as its outpatients and who are residing in the non- certified part of a SNF, or in another residential setting (e.g., a group home, assisted living facility or domiciliary care home), the hospital may bill for the services as hospital outpatient services if the services meet the requirements applicable to outpatient hospital therapy services, as set forth in the regulations and applicable Medicare manuals.    A hospital may make an arrangement with another entity such as an Outpatient Rehab Facility (Rehabilitation Agency) or a private practice, to provide therapy services to individuals who are registered as outpatients of the hospital.  These services must me et the requirements applicable to services furnished under arrangements and the requirements applicable to the outpatient hospital therapy services as set forth in the regulations and applicable Medicare manuals.  The hospital uses bill type 13X or 85X for  critical access hospitals to bill for the services that another entity furnishes under arrangement to its outpatients.   Where the provider is a public health agency or a hospital in a rural community, it may enter into arrangements to have outpatient physical therapy services furnished in the private office of a qualified physical therapist if the agency or hospital does not have the capacity to provide on its premises all of the modalities of treatment, tests, and measurements that are included in an adequate outpatient physical therapy program and the services and modalities which the public health agency or hospital cannot provide on its premises are not available on an outpatient basis in another accessible certified facility.    In certain settings and under certain circumstances, hospitals may not bill Medicare for therapy services as services of the hospital:    If a hospital sends its therapists to provide therapy services to patients of another hospital, including a patient at an inpatient rehabilitation facility or a long term care facility, the services must be furnished under arrangements made with the hospital sending the therapists by the hospital having the patients and billed as hospital services by the facility whose patients are treated.  These services wo uld be subject to existing hospital bundling rules and would be paid under the payment method applicable to the hospital at which the individuals are patients.    A hospital may not send its therapists to provide therapy services to individuals who are receiving services from an HHA under a home health plan of care and bill for the therapy services as hospital outpatient services.  For patients under a home health p lan of care, payment for therapy services (unless provided by physicians/NPPs) is included or bundled into Medicares episodic payment to the HHA, and those services must be billed by the HHA under the HHA consolidated billing rules.  For patients receivin g HHA services under an HHA plan of care, therapy services must be furnished directly or under arrangements made by the HHA, and only the HHA may bill for those services.   If a hospital sends its therapists to provide services under arrangements made by a SNF to residents of the Medicare -certified part of a SNF, SNF consolidated billing rules apply.  For arrangements specific to SNF Part A, see Pub. 100- 04, chapter 6, 10.4.  This means that therapy services furnished to SNF residents in the Medicare -certified part of a SNF cannot be billed by any entity other than the SNF.  Therefore, a hospital may not bill Medicare for PT/OT/SLP services furnished to residents of a  Medicare- certified part of a SNF by its therapists as services of the hospital.  NOTE :  If the SNF resident is in a covered Part A stay, the therapy services would be included in the SNFs global PPS per diem payment for the covered Part A stay itself.  If the resident is in a noncovered stay (Part A benefits exhausted, no prior qualifying hospital stay, etc.), but remains in the Medicare -certified part of a SNF, the SNF would submit the Part B therapy bill to its A/B MAC (A) .  SNF Setting  Applicable Rules  Medicare Part A or B  Consolidated Billing Rules Apply?  Hospital May Bill For Outpatient Services?  Part A (Medicare Covered / PPS) Resident in Medicare -certified part of a SNF  Yes No Medicare Part B Resident in Medicare- certified part of a SNF  Yes No Medicare Part B  Not a Resident in Medicare-certified part of a SNF  No Yes   A hospital may not send therapy staff to provide therapy services in non-residential health care settings and bill for the services as if they were provided at the hospital, even if the hospital owns the other facility or entity.  Examples of such non- residential settings include CORFs, rehabilitation agencies, ORFs and offices of physicians/NPPs or other practitioners, such as physical therapists.  For example, services furnished to patients of a CORF must be billed as CORF services and not as outpatient hospital services.  Even if a CORF contracts with a hospital to furnish services to CORF patients, the hospital may not bill Medicare for the services as hospital outpatient services. However, the CORF could have the hospital furnish services to its patients under arrangements, in which case the CORF would bill f or the services.   Psychiatric hospitals are treated the same as other hospitals for the purpose of therapy billing.   231 - Pulmonary Rehabilitation (PR) Program Services Furnished On or After January 1, 2010  (Rev. 11426; Issued: 05-20- 22; Effective: 01 -01-22; Implementation: 07-05-22)  Pulmonary rehabilitation (PR) means a physician-supervised program for chronic obstructive pulmonary disease (COPD) and certain other chronic respiratory diseases designed to optimize physical and social performance and autonomy. Effective January 1, 2010, Medicare Part B pays for PR if specific criteria are met by the Medicare beneficiary, the PR program itself, the setting in which it is administered, and the physician administering the program, as outlined below.  Covered Conditions:  As specified in 42 CFR 410.47, Medicare Part B covers PR for beneficiaries:   With moderate to very severe COPD (defined as GOLD classification II, III, and IV), when referred by the physician treating the chronic respiratory disease;  Who have had confirmed or suspected COVID- 19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks (effective January 1, 2022);   Additional medical indications for coverage for PR program services may be established through a national coverage determination (NCD).  PR must include all of the following components:   Physician -prescribed exercise. Physician -prescribed exercise means aerobic exercise combined with other types of exercise (such as conditioning, breathing retraining, step, and strengthening) as determined to be appropriate for individual patients by a physician. Each PR session must include physician- prescribed exercise.   Education or training. Education or training that is closely and clearly related to the individuals  care and treatment which is tailored to the individuals needs and assists in achievement of goals toward independence in activities of daily living, adaptation to limitations and improved quality of life. Education must include information on respiratory problem management and, if appropriate, brief smoking cessation counseling.   Psychosocial assessment. Psychosocial assessment means an evaluation of an  individuals mental and emotional functioning as it relates to the individuals rehabilitation or respiratory condition which includes an assessment of those aspects of an individuals family and home situation that affects the individuals rehabilitation treatment, and psychosocial evaluation of the individuals response to and rate of progress under the treatment plan.   Outcomes assessment. Outcomes assessment means an evaluation of  progress as it relates to the individuals rehabilitation which includes the following: (i) Evaluations, based on patient -centered outcomes, which must be measured by the physician or program  staff at the beginning and end of the program. Evaluations measured by program staff must be considered by the physician in developing and/or reviewing individualized treatment plans. (ii) Objective clinical measures of exercise performance and self -repor ted measures of shortness of breath and behavior.  Individualized treatment plan. Individualized treatment plan means a written plan  tailored to each individual patient that includes all of the following: (i) A description of the individuals diagnosis. (ii) The type, amount, frequency, and duration of the items and services furnished under the plan. (iii) The goals set for the individual under the plan. The individualized treatment plan detailing how components are utilized for each patient, must be established, reviewed, and signed by a physician every 30 days.   As specified at 42 CFR 410.47(e), the number of PR sessions are limited to a maximum of 2 1- hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the Medicare Administrative Contractor (MAC).   PR Settings:   Medicare Part B pays for PR in a physicians office or a hospital outpatient setting. All settings must have the following: (i) A physician immediately available and accessible for medical consultations and emergencies at all times when items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for direct supervision for physician office services, at 42 CFR 410.26, and for hospital outpatient services at 42 CFR 410.27, and (ii) The necessary cardio-pulmonary, emergency, diagnostic, and therapeutic life -saving equipment accepted by the medical community as medically necessary (for example, oxygen, cardiopulmonary resuscitation equipment, and defibrillator) to treat chronic respiratory disease.  PR Physician Standards:   Medical Director. Medical director means the physician who oversees the PR program at a particular site. The medical director is the physician responsible for a PR program and, in consultation with staff, is involved in directing the progress of individual s in the program and must possess all of the following: (1) Expertise in the management of individuals with respiratory pathophysiology.  (2) Cardiopulmonary training in basic life support or advanced cardiac life support. (3) Be licensed to practice medic ine in the State in which the PR program is offered.   Supervising Physician. Supervising physician means a physician that is immediately available and accessible for medical consultations and medical emergencies at all times items and services are being furnished to individuals under PR programs. Physicians acting as the supervising physician must possess all of the following: (1) Expertise in the management of individuals with respiratory pathophysiology. (2) Cardiopulmonary training in basic life support or advanced cardiac life support. (3) Be licensed to practice medicine in the State in which the PR program is offered.   (See Publication 100- 04, Claims Processing Manual, chapter 32, section 140.4, for PR  claims processing, coding, and billing requirements.)   232 - Cardiac Rehabilitation (CR) and Intensive Cardiac Rehabilitation (ICR) Services Furnished On or After January 1, 2010  (Rev. 11426; Issued: 05- 20-22; Effective: 01 -01-22; Implementation: 07 -05-22)  Cardiac rehabilitation (CR) means a physician -supervised program that furnishes physician prescribed exercise; cardiac risk factor modification, including education, counseling, and behavioral intervention; psychosocial assessment; and outcomes assessment.  Intensive cardiac rehabilitation (ICR) program means a physician -supervised program that furnishes CR and has shown, in peer -reviewed published research, that it improves patients cardiovascular disease through specific outcome measurements described in 42 CFR 410.49(c). Effective January 1, 2010, Medicare Part B pays for CR/ICR if specific criteria are met by the Medicare beneficiary, the CR/ICR program itself, the setting in which it is administered, and the physician administering the program, as outli ned below.  Covered Conditions:   As specified in 42 CFR 410.49, Medicare Part B covers CR and ICR for beneficiaries who have experienced one or more of the following:    An acute myocardial infarction (MI) within the preceding 12 months;   A coronary artery bypass surgery;   Current stable angina pectoris;   Heart valve repair or replacement;   Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;   A heart or heart -lung transplant.  Stable, chronic heart failure defined as patients with left ventricular ejection fraction of 35% or less and New York Heart Association (NYHA) class II to IV symptoms despite being on optimal heart failure therapy for at least 6 weeks, on or after Februa ry 18, 2014 for CR and on or after February 9, 2018 for ICR; or,  Other cardiac conditions as specified through a national coverage determination (NCD). The NCD process may also be used to specify non- coverage of a cardiac condition for ICR if coverage is not supported by clinical evidence.   CR and ICR must include all of the following components:   Physician -prescribed exercise. Physician -prescribed exercise means aerobic exercise  combined with other types of exercise (such as strengthening and stretching) as determined to be appropriate for individual patients by a physician each day CR/ICR items and services are furnished.