PGBA/ZPIC’S Assessing Overpayments for HHA-PT Services

Good Afternoon To All, Based upon a recent wave of overpayment assessments for PT-HHA servicves by PGBA-ZPIC’S, I thought it important that you each renew your familiarity with PGBA’S PT-HHA general guidelines and then review the LCD in more detail regarding the modalities your Agencies are providing.

LCD No. 99HH-021-L – Physical Therapy for Home Health

General Physical Therapy Guidelines:
1. Physical therapy services are covered services provided the services are of a level of complexity and sophistication, or the patient’s condition is such that the services can be safely and effectively performed only by a licensed physical therapist or under his/her supervision. Services normally considered to be a routine part of nursing care are not covered as physical therapy (i.e., turning a patient to prevent pressure injuries or walking a patient in the hallway postoperatively).

2. Covered physical therapy services must relate directly and specifically to an active written treatment regimen established by the physician, with input from the qualified physical therapist, and must be reasonable and necessary to the treatment of the individual’s illness or injury.

3. Additionally, in order for the plan of care to be covered, it must address a condition for which physical therapy is an accepted method of treatment as defined by standards of medical practice, and must be for a condition that is expected to improve materially within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program.

4. Therefore, physical therapy is only covered when it is rendered under a written treatment plan developed and approved by the individual’s physician to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration.

5. The therapist must document the patient’s functional limitations in terms that are objective and measurable.

Have a great day! CP

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