Plan N-No $20 Copay on Physical Therapy

[WCMason]

Can someone tell me what these codes are? Or a link to somewhere that says this information? I'm getting conflicting information from a few different carriers.

99201 to 99215. One set of codes for new patients and one set for existing patients (rate is a little higher for new patients to take into account administrative cost of setting up the new patient). Code is based on severity of the condition being treated and the amount of time spent with the doctor. The "copay" isn't really a copay. It's 20% coinsurance of the Medicare physicians fee schedule rate for that code, not to exceed $20. For a brief visit for a mild condition the "copay" can be as little as $8.

 

[Dix86]

Do these codes, if used correctly, eliminate that copayment/coinsurance amount they (client) would have to pay?

 

[WCMason]

Do these codes, if used correctly, eliminate that copayment/coinsurance amount they (client) would have to pay?

They don't eliminate the copay. They are the only codes for which there are copays.

 

[Dix86]

So, if I am understanding you correctly, you are saying all other posters on this thread are wrong and there is a $20 or 20% co payment for Physical therapy sessions?

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My question is really- Is there a way to receive physical therapy and avoid the co payment altogether.

 

[kgmom219]

So, if I am understanding you correctly, you are saying all other posters on this thread are wrong and there is a $20 or 20% co payment for Physical therapy sessions?

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My question is really- Is there a way to receive physical therapy and avoid the co payment altogether.

1. You are way too deep into this. You have no control over procedure/diagnosis codes used at a PT office

2. Technically, there IS coins/copay for PT visits. Unless you use certain codes. Telling a PT to use different codes to avoid the charges sounds like Medicare fraud to me.

3. If you purchase/sell N, you have a copay. N is a great plan. Except when you need extended therapy.

 

[WCMason]

So, if I am understanding you correctly, you are saying all other posters on this thread are wrong and there is a $20 or 20% co payment for Physical therapy sessions?

I didn't address PT specifically. Any claim using those codes will get the copay on a Plan N. PT uses a different code, so no copay if coded correctly, unless there is a doctor visit associated with the PT session (which I don't think happens much). I had a client complain to me that Plan N was a mistake because she was getting hit with copays for chiropractic care and wanted to switch to G or F. Instead, I told her the chiropractor's billing office was coding it wrong. She called them and the copays went away; she still has Plan N. Sounds like this case may be similar.

On a similar note, there is a different code for urgent care center than for ER visit, so the "up to $50" copay that Plan N has doesn't apply to an urgent care visit. It's all in the coding.

When Plan N was introduced in 2010 CMS put out a memo on it. Very helpful.

http://www.cms.gov/Medicare/Health-Plans/Medigap/downloads/Plan_N_Guidance2.pdf

 

[Dix86]

Thanks for your help. Much appreciated. I'm not looking to commit medicare fraud to the above poster, just trying to help a client avoid this bill if possible.

 

[WCMason]

1. You are way too deep into this. You have no control over procedure/diagnosis codes used at a PT office 2. Technically, there IS coins/copay for PT visits. Unless you use certain codes. Telling a PT to use different codes to avoid the charges sounds like Medicare fraud to me. 3. If you purchase/sell N, you have a copay. N is a great plan. Except when you need extended therapy.

You may not be deep enough. PT CPT codes are not the same as doctor visit CPT codes and not subject to a copay unless there is also a doctor visit associated with the therapy session. Extended therapy would not make Plan N less than the great plan that it is, and it's doubtful that a PT provider would use doctor visit codes for what they do, which has a specific and different code for every type of PT.

 

[kgmom219]

You may not be deep enough. PT CPT codes are not the same as doctor visit CPT codes and not subject to a copay unless there is also a doctor visit associated with the therapy session. Extended therapy would not make Plan N less than the great plan that it is, and it's doubtful that a PT provider would use doctor visit codes for what they do, which has a specific and different code for every type of PT.

Ok, this is getting interesting.

Example 1: My mother recently had her hip replaced. (She's on G). The home health people tried to tell her that she was going to owe $12.60 for every PT visit. (That went really well for them). But the nurse visits were free. They "made a mistake" and thought she was on N.

Example 2: One of my groups is a physical therapists office. I asked them what that do for people on Medicare. (They don't take Advantage plans). Their billing person told me she loves F&G, but that N drove her nuts, because there is a different charge for every visit. I asked if it was ever free and the answer was "very rarely". (This answer is what drove my mother to G.)

Throwing this out there, because this may be part of the problem. In Texas, you cannot see a PT without docs orders. We have a bill in front of the legislature to change that right now. No clue if that plays into billing or not.

My two cents

 

[WCMason]

Ok, this is getting interesting. Example 1: My mother recently had her hip replaced. (She's on G). The home health people tried to tell her that she was going to owe $12.60 for every PT visit. (That went really well for them). But the nurse visits were free. They "made a mistake" and thought she was on N. Example 2: One of my group is a physical therapists office. I asked them what that do for people on Medicare. (They don't take Advantage plans). Their billing person told me she loves F&G, but that N drove her nuts, because there is a different charge for every visit. I asked if it was ever free and the answer was "very rarely". Throwing this out there, because this may be part of the problem. In Yexas

Most of the misinformation I see comes from providers, and this looks like two good examples of it. They were likely creating their own problems by miscoding, and unnecessarily costing their patients money.

My most recent example of provider stupidity is two calls I've gotten in last month from clients who told me their doctors would not take their Plan G med supp because the doctor--a Medicare provider--was not contracted with that carrier. In the first case I got the client's permission to call the doctor's billing office to explain how it works. She was unmoved, adamant that there would be no supplemental coverage because they are not contracted. No amount of explaining how med supps work got through. I called the client back and told her to ignore the doctor, let them file the claim, and assured her she would be covered. I included the story in my last client newsletter to head off future client scares over doctors giving bad information.