Medicare Part A Case Study

The eligibility criteria for Medicare part A and Medicare part B are one in the same. An individual must be 65 or older and has paid into the medicare funds pool for at least 10 years, or has been diagnosed with ALS, ESRD, or suffers from severe disability.1,2 Medicare Part B, unlike Medicare part A, covers outpatient services such as doctor's visits and rehabilitation service. Medicare part B benefits are accompanied by a payment cap for outpatient service that Medicare will cover which is $1,960 annually.2 After the cap has been reached or exceeded the beneficiary may be responsible for the cost of additional service at their discretion.2 Healthcare Providers may however, provide CMS with documentation as well as a written request for additional

The most common medicare violations are centered around billing and coding as well as documentation requirements established by CMS. If there are any discrepancies with either billing and coding or within a therapist documentation there can be serious legal implications for the therapist and facility. In conjunction with legal proceedings the possibilities of monetary fines and refunding of reimbursements exist, as part of RAC audits that retrospectively audit claims as far back as 3

Physical therapy assistants are educated and skilled in the domain of therapeutic interventions, however they do not receive as much formal education on the examination and evaluation aspects of patient care. With that being said employing the use of PTA’s can run the risk of violating CMS regulations as it relates to documentation. PTA’s may treat Medicare B patient under the supervision of a credential physical therapist meaning he or she must be on site.3,7 PTA’s can write daily treatment notes which are co-signed by a credentialed PT who has established the plan of care.3,7 PTA’s however can not perform evaluations or establish plan of cares as well as complete the required progress note for every 10th visit.3,7 A clear violation of these regulations would be allowing a PTA to treat a medicare B patient without the supervision of a physical therapist and complete the progress note on the tenth visit. The physical therapist overseeing the episode of care should constantly communicate with the PTA in order to document an appropriate progress note and discharge previously established G-codes for new ones in accordance with altering the plan of