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Medicare Reimbursement for Outpatient Therapy Services (Fee Schedules)

If you are a therapist or healthcare provider who provides outpatient therapy services to Medicare patients, then you're likely aware of the Centers for Medicare and Medicaid Services (CMS) reimbursement program. The CMS reimburses for outpatient therapy services under Medicare Part B through the Medicare Physician Fee Schedule (MPFS). It might seem complicated to understand, but this post is here to break it down for you.




The CMS has developed a fee schedule that covers work expenses, practice expenses, and malpractice expenses for each modality and procedure (CPT code) that therapists provide to their Medicare patients. The amount that CMS reimburses is dependent upon the area in the country that you're providing the outpatient therapy services. At the moment, there are 91 localities in the encompassing United States, Puerto Rico, and Guam.


So, how can you find your own reimbursement information?

One way is to follow the link provided, click "start" on the first page, choose your preferred pricing information, and click "next." Under "Select Carrier Option," choose "Specific Locality," then click "next." Select your locality, and complete the CPT code(s) or range of CPT codes you want pricing information on. Keep in mind that in all settings except critical access hospitals (CAH's), the non-facility rate applies for outpatient therapy services.



When it comes to reimbursement rates, it's important to note that CMS makes annual adjustments to fees based on the physician work needed, practice expenses, and malpractice expenses associated with each modality and procedure code. It's essential to stay up-to-date with these adjustments, as they can impact your revenue.


Additionally, CMS implemented a "therapy cap" in the past to limit outpatient therapy expenses for patients receiving Medicare Part B benefits. However, as of 2018, this cap no longer exists. Nevertheless, there are still outpatient therapy services limitations. For instance, Medicare beneficiaries are eligible for up to $2,080 per therapy year, which is the amount that applies to physical therapy and speech-language pathology services combined. For occupational therapy, the limit is different, at $2,080, which is inclusive of speech-language therapy and physical therapy services.


Another crucial factor to consider regarding reimbursement is the impact of the Merit-based Incentive Payment System (MIPS). This program aims to incentivize healthcare providers as a result of quality of care and cost reduction. Over the years, CMS has made adjustments to the criteria to get involved in the program. In contrast, it will be ideal to keep apprised of the latest changes to ensure the success of your outpatient therapy practice.






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