Page 185 - Medicare Benefit Policy Manual

Therapy services are payable when furnished in the home at the same physician fee
schedule payment rates as in other outpatient settings. Additional expenses incurred by
providers of outpatient therapy due to travel to the beneficiary are not covered.

Under the Medicare law, there is no authority to require a provider to furnish a type of
service. Therefore, a hospital or SNF may furnish therapy to its inpatients without having
to set up facilities and procedures for furnishing those services to its outpatients.
However, if the provider chooses to furnish a particular service, it may not charge any
individual or other person for items or services for which the individual is entitled to have
payment made under the program because it is bound by its agreement with Medicare.
Thus, whenever a hospital or SNF furnishes outpatient therapy to a Medicare beneficiary
(either directly or under arrangements with others) it must bill the program under Part B
and may charge the patient only for the applicable deductible and coinsurance.

220.2 - Reasonable and Necessary Outpatient Rehabilitation Therapy
Services
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)

References: Pub. 100-08, chapter 13, §13.5.1,
42CFR410.59,
42CFR410.60

A. General

To be covered, services must be skilled therapy services as described in this chapter and
be rendered under the conditions specified. Services provided by professionals or
personnel who do not meet the qualification standards, and services by qualified people
that are not appropriate to the setting or conditions are unskilled services. A service is
not considered a skilled therapy service merely because it is furnished by a therapist or by
a therapist/therapy assistant under the direct or general supervision, as applicable, of a
therapist. If a service can be self-administered or safely and effectively furnished by an
unskilled person, without the direct or general supervision, as applicable, of a therapist,
the service cannot be regarded as a skilled therapy service even though a therapist
actually furnishes the service. Similarly, the unavailability of a competent person to
provide a non-skilled service, notwithstanding the importance of the service to the
patient, does not make it a skilled service when a therapist furnishes the service.

Skilled therapy services may be necessary to improve a patient’s current condition, to
maintain the patient’s current condition, or to prevent or slow further deterioration of the
patient’s condition. For further information see 220.2, subsections C (Rehabilitative
Services) and subsection D (Maintenance Programs).

Services that do not meet the requirements for covered therapy services in Medicare
manuals are not payable using codes and descriptions as therapy services. For example,
services related to activities for the general good and welfare of patients, e.g., general