PT billing question

[powermd]

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Is there a difference between what Medicare pays PT in an outpatient (private practice) setting vs a hospital outpatient department setting? Is there an associated hospital facility fee associated with PT codes?

With respect to medical procedures two bills are submitted for Medicare patients, one for the physician component of the work, the other for the technical component attributable to the hospital facility.

This split only exists for Medicare, private insurances do not ordinarily participate in this system known as "provider based billing".

I'm curious if this split billing is associated with PT codes. Our on-site physical therapist doesn't know.

 

[jesspt]

There is no associated hospital facility fee with the typical physical therapy CPT codes. And, to the best of my knowledge CMS pays the same if treatment is provided in a hospital outpatient department clinic or in a private, community-based PT clinic. Several years ago, hospital outpatient departments were exept from the CMS annual therapy cap, but that has now changed, and essentially all therapy providers are now restric by the same cap number - $1920 per year.

As an aside, hospital outpatient departments tend to charge significantly higher fees for PT services compared to sommunity based PT clinics - see this reference.

 

[NewDPT31]

I know you asked about Medicare, but FYI, with Medicaid/public aid, some states have different reimbursement rates for non profit hospitals vs for profit places. For example, in Chicago, at my outpatient Non profit hospital, we receive $111.55 per patient, regardless of how long we see them. While at the other hospital I work at, which is For profit(just like all private PT practices) the same patient seen would be reimbursable at $9/unit(if over 21, 12.99 for under). Medicare is the same regardless of where you go.

 

[truthseeker]

There is no associated hospital facility fee with the typical physical therapy CPT codes. And, to the best of my knowledge CMS pays the same if treatment is provided in a hospital outpatient department clinic or in a private, community-based PT clinic. Several years ago, hospital outpatient departments were exept from the CMS annual therapy cap, but that has now changed, and essentially all therapy providers are now restric by the same cap number - $1920 per year.

As an aside, hospital outpatient departments tend to charge significantly higher fees for PT services compared to sommunity based PT clinics - see this reference.

A couple comments: 1) the charges for services at hospitals are often higher but not always. It really depends upon the market the hospital is in. We have a small hospital and my department is the only PT in town really. We do "compete" with 8 chiropractors (in a town of 5300, that is what would be considered over-saturation) so our costs are held down by that competition.
2) we are also a critical access hospital so we are supposed to be receiving 101% of our costs from Medicare. No more, no less. so, if we charge too much we have to give it back at the end of the year and no CFO likes to do that.

 

[Bluecase]

Medicare changes its reimbursement for CPT codes based on different regions in the country - so a practice could receive more for one unit billed in new york city versus jackson mississippi purely based on cost of living and overhead associated with running a clinic.

Also with regards to medicare - it doesn't matter if its a hospital based outpatient or Joe Shmo outpatient. They could charge 5,000 dollars per unit if they wanted but Medicare will only reimburse on what their rate is for a specific code (therex, theract, NMRE, etc...). That way no one facility is receiving different amounts of money for different the same provided treatments. Also, medicare pays only 80% of that reimbursement rate, the patient is responsible for the other 20% if it is billed under Medicare Part B (most outpatient facilities). Medicaid is different and I am not as familiar with the laws.