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Many people need Medicare coverage for occupational therapy at some point. As we grow older, health conditions and injuries become more likely. Due to this, the chances of needing some form of therapy increases. Fortunately, Medicare coverage for occupational therapy is available for enrollees. Coverage also includes some physical and speech therapy benefits.
Although, a common misconception is that physical therapy (PT) and occupational therapy (OT) are the same. This can be problematic as that’s not at all true. In fact, PT and OT are widely different.
While PT is for treating or improving a person’s condition; OT helps patients learn how to function and carry out daily activities with that condition.
For example, let’s say Conner has a shoulder injury that requires physical therapy to regain strength and mobility. Conner also needs occupational therapy to teach him how to carry out everyday activities during his recovery.
In the case Conner suffers from a stroke, he may benefit from speech therapy.
Medicare Coverage for Occupational Therapy
Beneficiaries may not receive coverage for therapy unless it’s medically necessary to treat an impairment. Health care providers must confirm and document the medical reason(s) for Medicare to cover the costs. Meaning, doctors must give proper diagnosis codes that support their order for a patient’s therapy for treatment. Medicare may deny a request for therapy, it’s possible the wrong diagnosis code was chosen.
When this happens, patients should contact healthcare providers. They may have another code to better support a condition.
While Part C coverage offers the benefits of both Parts A and B in addition to extra benefits for the most part C plans.
What Medicare Pays for Occupational Therapy
Patients receiving occupational therapy from an outpatient facility will have Medicare coverage under Part B. Facilities include doctor’s or therapist’s office, rehabilitation facilities, clinics, hospital (outpatient care), or in a patient’s home. Doctors or therapists must prescribe therapy, provide a care plan, and regularly review it. All services must come from a Medicare-certified therapist.
Occupational Therapy at Home
The majority of people take or drive themselves to a doctor’s office or outpatient facility to receive their treatment. Unfortunately, some individuals don’t have that option. Home therapy services may be part of coverage for people that are unable to leave the house. Although, to receive home health services specific requirements must be met before Medicare Part A will cover costs.
First, to get home health services a person must be homebound. Medicare classifies this as someone that’s unable to leave their home without assistance. If leaving the house is too physically demanding or a medical condition is too severe to recommend leaving the house.
The second requirement is to receive therapy from qualifying professionals. Therapy providers must create a care plan that focuses on improving or maintaining a person’s condition or injury.
Although, services aren’t meant for permanent means of treatment. However, therapy should expand over a reasonable length of time to ensure the care plan goal is met.
Medicare Limits for Occupational Therapy
Therapy services limits reflect by the total cost, rather than by a specific number of visits. The amount per service depends on the therapist that provides care. An example, one therapist may charge more than another for the same service. Although, like many services Medicare covers, beneficiaries must pay a 20% coinsurance amount at the time of each visit.
However, coinsurance amounts can become costly if a patient has multiple therapy sessions. Beneficiaries should contact their Medicare agent to discuss the cost of coinsurance and review other options for coverage.
Many times, people enroll in the wrong plan unknowingly – simply because they don’t understand all their options. For some, a simple phone call leads them right to the best plan for their situation.
It’s important to make sure you have the right plan to avoid gaps in coverage which may lead to excessive out-of-pocket expenses.
The Therapy Cap
Medicare paid for therapy services while limiting how much it would pay for. Congress passed the Bipartisan Budget Act of 2018 ending the therapy cap. While this is true, it doesn’t mean unlimited therapy for beneficiaries. The federal government wants to ensure beneficiaries aren’t overutilizing therapy services.
Medicare pays for up to $2,010 for physical and speech therapy combined and a separate amount of $2,010 for occupational therapy. However, isn’t a cap limit, as it doesn’t prevent patients from receiving additional therapy. Consider this dollar-amount as a “threshold” limit.
Once that amount is spent on treatment services within a single calendar year, healthcare providers must add proper billing codes (KX modifiers) to patients’ medical records. This modifier acts as a flag to notify the government, that the cost of a patient’s therapy services has met a certain amount.
After the amounts reach $3,000 for costs of service, Medicare may review the patient’s case to ensure continuing therapy is medically necessary.
Therapists should explain why additional sessions are needed and clearly document it in a patient’s medical record. Otherwise, Medicare may deny coverage for additional therapy for that calendar year. Beneficiaries may file a claim to appeal the decision if therapy is necessary.
Further, Medicare physical therapy cuts could impact your access to care.
Understanding Your Medicare Coverage for Occupational Therapy
Medicare offers coverage for occupational therapy, physical therapy, and speech-language pathology services. Although, depending on the plan, the cost of coverage may vary. Before the 2018 Act, beneficiaries had a cap limit on how much Medicare would pay for therapy services.
The cap limit on therapy sessions no longer applies. However, the federal government requires Medicare to audit and review cases once $3,000 is spent on therapy services.
The annual cap limit is in place to help prevent patients from overusing benefits. If therapy sessions are properly documented as medically necessary, coverage is available.
It can be difficult or a lot to take in all at once. We understand. Medicare likes to change policies and rules often; things can get mixed up. Don’t worry, that’s what we’re here for. Let one of our agents walk you through it.
Agents can help clear up any Medicare confusion by answering the questions you may have. Also, they compare plan rates and find the best coverage for your therapy needs, without breaking the bank! Give us a call today at the number above or fill out an online rate comparison form.