Physical medicine and rehabilitation billing

Physical Medicine and Rehabilitation Billing (PM&R Billing)

Physical medicine and rehabilitation (PM&R) is an area of medicine that deals with the treatment of physical limitations to prohibit the onset (slow the progression) of the patient’s disability, as well as the impairments after an injury or illness. Physical medicine and rehabilitation treatments and therapies are usually done over a period of time.

Physical medicine and rehabilitation billing is a straightforward billing practice that involves the charges that a medical facility charges for their physical medicine and rehabilitation services. Despite being a simple and straightforward billing practice, PM&R billing practices has been the subject for multiple audits due to the nature of the services.

Issues of fraud and non-compliance are common issues and accounts for a majority of improper claims and excessive payments. A huge part of physical medicine and rehabilitation claims are paid directly to the physicians, therefore increasing the potential for being incorrectly coded and incorrectly billed to the payer or the insurer.

Guidelines for Billing Physical Medicine and Rehabilitationv

Healthcare insurers like the Centers for Medicaid and Medicare Services (CMS) and United Healthcare (UHC) have compiled several guidelines to accurately bill physical medicine and rehabilitation services. These guidelines have been compiled based on the data that the Local Coverage Determinations of the CMS has collected.

Based on these guidelines, the usual duration of a therapy session does not exceed one hour. For this reason, several private health insurers have made it available for medical facilities to use reimbursement codes in any combination, up to a maximum of four timed codes, per date of service, provided by the same specialty physician or another health care professional.

Claim Provisions

Medicare allows physicians to submit billable claims for physical therapy service that they do not perform personally. These provisions by CMS to allow physicians to bill without being physically present during the physical therapy opens up a discussion about insurers being vulnerable to incorrect billing practices.

Insurers require physicians to have at least a hand in the diagnostic process, and that the physician is wholly responsible for whoever is administering or supervising the physical therapy sessions.

Reimbursement Requirements

By law, reimbursing for physical medicine and rehabilitation services require the patient to be under the care of a physician – a doctor of medicine, preferably related to physical medicine and rehabilitation, with specialties in osteopathy, optometry, or podiatric medicine. Reimbursing for services also requires that the patient be treated in a medical facility, with an established plan for care.

The plan of care for the patient will completely detail the duration of the therapy, the frequency, the type of therapy the patient is having, and the amount for the services. If a plan of care is set to be administered over a long period of time, it has to be recertified by the physician periodically.

The plan of care must contain the following information: the patient’s related past history, the patient’s diagnosis that warrants physical therapy, physician’s orders, the end-goal for the therapy and prognosis.

Miscellaneous Billing

In situations where physical therapists and non-doctors of medicine are supervising the sessions and therapy, the patient’s physical therapy sessions can be billed directly to the therapist as long as certain guidelines are met. The physical therapist supervising and administering the therapy must be licensed in the state where the physical therapy service is conducted. The session must adhere to the coverage guidelines specified by Medicare for outpatient physical therapy.

Physical therapists can provide physical medicine and rehabilitation services at their own offices, or a physician’s office, a nursing home, a rehabilitation center, or a hospital. Services can be rendered by any individual, licensed or not, to administer physical therapy sessions to the patient. This is because the physician assumes responsibility for the physical therapy session.

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