Your patient currently does not currently qualify for skilled care under Medicare Part B.

This means you can see this patient for non-covered services under wellness and charge them cash for their care. Wellness services include fitness programs, health maintenance activities, and other interventions (ie. dry needling) that fall outside the purview of traditional insurance billing. Please be aware that if you are providing both covered and non-covered services under the same treatment plan, you are still required to bill Medicare for the covered services.

For the non-covered services, clinicians are able to set their own rates and bill patients directly, as these services do not meet the criteria for medically necessary physical therapy and are not able to be billed to Medicare. Because these services are considered non-covered, the patient cannot seek reimbursement from Medicare either.

NOTE: When a patient is actively utilizing their Medicare A benefit for Home Health or Hospice services, they cannot simultaneously utilize their Medicare B benefit. This means you CAN provide wellness services in this scenario. Make sure to see notes below regarding use of the ABN Waiver for these patients.

To read more about the ‘Non-Opt Out' Policies for Physical Therapists, refer to the Medicare Benefit Policy Manual Chapter 15, Section 40.4 which does not include Physical Therapists under the list of Practitioners who can elect to ‘Opt Out'.’

Do I Need an ABN Waiver?

It depends:)

Wellness services, like fitness programs or health maintenance activities, as described above do NOT require an ABN to be signed as these services are considered non-covered.

However, if a patient is currently being seen by a Medicare A provider of ANY TYPE (Nursing, PT, OT, SLP, HHA), and requesting to pay privately for services to supplement the care they are receiving, then the patient DOES need to sign an ABN. While the level of therapy you will provide might typically be considered a covered service, it is currently considered non-covered due to the patient actively utilizing their Medicare A benefit. To learn more about the ABN Waiver, click here.

Changes in Status

Please be aware that If you are seeing a Medicare beneficiary privately for wellness services, and they present with new or worsening clinical impairments that are now impacting their function, it is illegal and unethical to continue to charge them for their care related to this diagnosis. In this scenario, you will need to either see them through their Medicare B benefit if you are a credentialed provider, bill Medicare as a non-participating provider, or refer out to another Medicare B provider to provide their covered care. To evaluate their current medical-necessity in light of changes in status, choose the Back button below to start from the beginning.