A change to institutional billing policies for physical therapy services under Medicare is causing confusion — and in some instances, denials for claims. APTA is now able to shed some light on the issue, which is centered on the use of an attending clinician's National Provider Identifier on certain claim forms, and the eligibility of PTs to serve as attending clinicians for purposes of billing under those forms.
The change, implemented in April, is intended to stop the use of an institutional NPI on claims submitted through the CMS-1450 form, also known as the UB-04, when what's actually required is the attending clinician's NPI. The problem? PTs aren't eligible to serve as attending providers in these instances, even for physical therapy claims. Instead, CMS requires that the 1450 forms list an attending physician.
Unfortunately, CMS didn't call attention to its longstanding determination around whether PTs qualify as an attending clinician in these settings, and individual Medicare Administrative Contractors haven't provided much guidance on compliance. As a result, several institutional settings where PTs practice have experienced billing problems when they’ve attempted to list the attending PT's NPI on the claim form to comply with the April change.
APTA contacted CMS about the issue. CMS confirmed that the appropriate approach to billing physical therapy services through the 1450 form is to list the certifying physician for the physical therapy plan of care. The agency pointed to passages in the Medicare benefit manual (Chapter 15, Page 174) and claims processing manual (Chapter 5, Page 16) as the places to go for guidance on how to identify the appropriate attending clinician NPI for institutional claims.
Bottom line: If you're an institutional setting that submits physical therapy claims on CMS-1450 (aka UB-04), be sure to list the certifying physician for the plan of care, not the PT, on the form. If you experience any continuing or new issues related to claims for physical therapy services in institutional settings, contact firstname.lastname@example.org.