Medicare does not cover performance training, wellness services, injury prevention programs, or dry needling. If you are a Medicare beneficiary, we will clearly outline what services are covered and what services would be considered cash-pay prior to beginning care.

1. Purpose

This policy outlines how 1 of 1 Performance & Rehab complies with federal Medicare regulations while operating as a primarily cash-based physical therapy practice.

The clinic is committed to:

• Full regulatory compliance

• Ethical billing practices

• Transparent patient communication

• Proper documentation of medical necessity

2. Medicare Participation Status

1 of 1 Performance & Rehab does not opt out of Medicare (as physical therapists are not permitted to opt out under federal law).

If medically necessary covered physical therapy services are provided to a Medicare beneficiary:

• The clinic will submit claims to Medicare.

• The patient will be responsible only for applicable deductible and coinsurance.

• The clinic will not privately contract for covered services.

3. Covered vs. Non-Covered Services

A. Covered Services

Medicare will be billed when services meet all of the following:

• The patient is a Medicare beneficiary.

• Services are medically necessary.

• Services require skilled intervention of a licensed physical therapist.

• Documentation supports the need for care.

• Services fall within Medicare benefit categories.

Examples may include:

• Therapeutic exercise (97110)

• Neuromuscular re-education (97112)

• Manual therapy (97140)

• Therapeutic activities (97530)

• Gait training (97116)

B. Non-Covered Services

Medicare does not cover services that are:

• Performance training

• Wellness or fitness programs

• Injury prevention programs

• General strength & conditioning

• Maintenance without skilled need

• Dry needling (CPT 20560, 20561)

• Experimental or non-recognized modalities

When non-covered services are provided:

• Medicare will not be billed.

• The patient will be informed in advance.

• An Advance Beneficiary Notice (ABN) will be issued when required.

• The patient may choose to pay out-of-pocket.

4. Advance Beneficiary Notice (ABN)

An ABN will be issued when:

• Services may be denied as not medically necessary.

• A service is statutorily non-covered (e.g., dry needling).

• Care extends beyond what Medicare is likely to approve.

The ABN will:

• Clearly explain why denial is expected.

• Provide cost estimates.

• Offer patient options.

• Be signed prior to service delivery.

Signed ABNs will be retained in the patient’s medical record.

5. Medical Necessity & Documentation

All Medicare claims will include documentation supporting:

• Evaluation findings

• Functional limitations

• Measurable goals

• Skilled intervention

• Objective progress

• Plan of care certification (when required)

Re-certifications will follow Medicare timelines and requirements.

6. Plan of Care Certification

For Medicare beneficiaries:

• A Plan of Care (POC) will be established after evaluation.

• The POC will be certified by an authorized physician or non-physician practitioner as required by Medicare regulations.

• Re-certification will be obtained as required under Medicare rules.

7. Cash-Based Services for Medicare Beneficiaries

The clinic may provide cash-based services to Medicare beneficiaries only if:

• The service is not covered by Medicare.

• The service is not medically necessary under Medicare guidelines.

• The patient is informed in writing.

• No covered service is improperly bundled into a cash package.

Covered services will never be reclassified as wellness to avoid billing Medicare.

8. Compliance Monitoring

1 of 1 Performance & Rehab will:

• Periodically review documentation standards.

• Monitor ABN use.

• Ensure CPT coding accuracy.

• Follow Missouri and federal regulations.

• Update policies when Medicare regulations change.

9. Patient Transparency

Patients will be informed:

• Whether Medicare will be billed.

• Which services are covered.

• Which services are cash-based.

• Their estimated financial responsibility.

Written financial policies will be provided at intake.