HI 00610.370 Outpatient Physical Therapy and Speech Pathology
Coverage of physical therapy (and speech pathology services provided on or after January
1, 1973) furnished on an outpatient basis includes such services furnished by or under
arrangements made by a participating provider of services. The patient is responsible
only for the regular Part B deductible and coinsurance amounts.
For the purposes of this coverage, the term “provider of services” is extended to include approved clinics, rehabilitation agencies, and public health
agencies as well as participating hospitals, SNF's and HHA's. To qualify as providers
of services, clinics, rehabilitation agencies, and public health agencies are required
to meet certain conditions enumerated in the law and regulations and to enter into
an agreement with the Secretary.
Payment may be made for outpatient physical therapy services and outpatient speech
pathology services furnished by a participating provider of services if a physician
has certified the individual needs physical therapy or speech pathology services and
a plan for furnishing such services has been established and is periodically reviewed
by the physician; and such services are furnished while the individual is under the
care of a physician. Effective January 1, 1981, plans of treatment for outpatient
speech pathology services may be established by either the physician or the speech
pathologist providing such services.
Such services may be furnished an eligible outpatient in his home (including an institution
serving as his place of residence, such as an old age home), in the provider's outpatient
department, or to inpatients of other health facilities.
Inpatients of participating hospitals or SNF's who have exhausted Part A benefits,
or who are ineligible for Part A benefits may receive covered outpatient physical
therapy services by the provider effective October 30, 1972 and speech pathology services
effective January 1, 1973. Patients who are in an institution which does not furnish
physical therapy or speech pathology services may receive such services as an outpatient
of another participating provider of service.
Providers of outpatient physical therapy and speech pathology services that have inpatient
facilities, other than participating hospitals and SNF's, may not furnish covered
outpatient physical therapy or speech pathology services to their own inpatients.
However, since the inpatients of one institution may be considered the outpatients
of another institution, all providers of outpatient physical therapy and speech pathology
services may furnish such services to inpatients of another health facility. The certified
distinct part of an institution is considered to be a separate institution from a
nonparticipating remainder. Consequently, when only part of an institution is certified
as a participating provider of services, that certified distinct part may render covered
outpatient physical therapy or spch pathology services to the inpatients of the noncertified
remainder. The certified part bills the program under Part B for outpatient physical
therapy and speech pathology services it furnishes to inpatients of the noncertified
While outpatient physical therapy and speech pathology are payable when furnished
in the home, when added expense is caused by a visit to the home, a question is raised
as to whether the rendition of the service in the home is reasonable and necessary.
Where the patient is not confined to his home, such added expense cannot be considered
as reasonable and necessary for the treatment of an illness or injury since the home
visit is substantially more costly than the medically appropriate and realistically
feasible alternative pattern of care; e.g., in the facility's outpatient department.
Consequently, these additional expenses incurred by providers due to travel to a person
who is not homebound are not covered.
There is no authority to require a provider to furnish a type of service. Therefore,
a hospital or SNF may furnish physical therapy or speech pathology to its inpatients
without having to set up facilities and procedures for furnishing physical therapy
or speech pathology to its outpatients. However, if the provider chooses to furnish
a particular service, it is bound by its agreement not to charge any individual or
other person for items or services for which the individual is entitled to have payment
made under the program. Thus, whenever a hospital or SNF furnishes outpatient physical
therapy or speech pathology to a Medicare beneficiary (either directly or under arrangements
with others) it must bill the program under Part B and may only charge the patient
for the applicable deductible and coinsurance.