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 part.

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.


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