If a Medicare patient is readmitted to the hospital, does she have to be discharged from PT/OT?

Mya asked...

If a Medicare patient is receiving outpatient services, is it an absolute that if this patient is readmitted to the hospital that he/she must be discharged from PT/OT?

Expert Answer

You're asking a question that's really about a medical decision, not about Medicare coverage. If a patient's outpatient physical therapy and occupational therapy (PT/OT) is medically necessary as determined by a medical order (prescription) from his or her doctor, and Medicare Part B agrees that it is medically necessary, Medicare Part B will cover it. If outpatient physical therapy and occupational therapy has begun but is interrupted by an inpatient hospital stay, whether it starts up again after the patient is released from the hospital is a medical decision to be made by the patient's doctor, based on the patient's medical need for that therapy and whether or not he or she is physically capable of safely receiving the therapy. There is no "absolute" Medicare rule that determines this. (The patient might even continue to get some therapy while an inpatient, but that would be covered by Medicare Part A hospital insurance, separate from Medicare Part B outpatient coverage.)

An important issue, however, about Medicare Part B coverage for outpatient physical or occupational therapy is the yearly limit on how much Medicare will pay, depending on where the patient receives the care. If the patient receives physical therapy or occupational therapy anyplace other than a hospital outpatient department -- such as in a doctor's or therapist's office, or at home -- Medicare will only pay up to a yearly amount of $1,860 for each type of therapy. After that, the patient is personally responsible for the full amount. If the patient receives either type of therapy at a hospital outpatient department, there is no such yearly dollar limit on what Medicare Part B will pay. However, there is a patient copayment for each visit. Also, a hospital outpatient department may charge more than the Medicare-approved amount for such therapy, the patient being personally responsible for the difference between the two amounts, so it's important to find out ahead of time whether the hospital will accept the Medicare-approved amount as the total charges, or whether instead they intend to charge more than the amount Medicare approves.