It is possible to receive both home health and outpatient physical therapy, but only under highly specific circumstances that navigate strict federal regulations, primarily those set by Medicare. The general rule is that you cannot be receiving both types of care simultaneously because of how the government pays for these services. Successfully managing both requires precise coordination and documentation to prove that the two services are entirely distinct and non-duplicative.
Distinguishing Home Health and Outpatient Physical Therapy
Home Health Physical Therapy (HHPT) is provided by a certified home health agency, with the therapist traveling to the patient’s residence. This care is covered under Medicare Part A as part of a comprehensive, intermittent skilled care plan. The focus of HHPT is functional recovery within the home environment, such as safely navigating stairs, transferring in and out of bed, and performing daily tasks.
Outpatient Physical Therapy (OPPT) takes place in a clinic, hospital, or private office, requiring the patient to travel to the facility. OPPT is covered under Medicare Part B. Outpatient clinics offer access to specialized equipment, such as treadmills, weight machines, and complex modalities that are not practical to bring into a private home.
The Homebound Status Requirement
The primary barrier to receiving both types of therapy is the Medicare requirement for “homebound status” to qualify for Home Health services. To be considered homebound, a patient must have an illness or injury that restricts their ability to leave the home without considerable and taxing effort, or the assistance of a supportive device or another person. Leaving the home must be infrequent, of short duration, or solely for the purpose of receiving medical treatment.
Regularly traveling to an outpatient clinic for physical therapy, which is not considered an intermittent medical appointment, can invalidate the homebound status. If the patient is determined to be leaving the home routinely and without taxing effort, they no longer qualify for the Home Health benefit. Losing homebound status results in the termination of the entire Home Health care plan, including skilled nursing and other services.
Conditions for Medically Necessary Concurrent Therapy
The biggest hurdle is that Medicare generally prohibits paying for Part B services, like OPPT, when the patient is actively receiving skilled services under a Part A Home Health plan of care. This is due to consolidated billing rules, which bundle payment for therapy services into the Home Health episode rate. The Home Health Agency is responsible for providing all necessary rehabilitation services during this time.
In rare, exceptional circumstances, concurrent care may be justified if the services are for two entirely separate conditions with distinct, non-overlapping goals. For example, a patient receiving Home Health for mobility training related to a recent hip fracture might concurrently need specialized outpatient therapy for a chronic, unrelated neurological condition, such as Parkinson’s disease.
The Part B provider must document that the specialized equipment or expertise needed for the chronic condition is not available or cannot be effectively provided by the Part A Home Health Agency. Rigorous documentation is required to prove that the outpatient service is not a duplication of the home health service.
The outpatient clinic must establish a plan of care with goals demonstrably different from the home health plan. Both providers must detail the unique diagnosis, treatment, and goals for their respective services to justify the medical necessity of both.
Coordination and Billing Considerations
The administrative burden and financial risk associated with concurrent care are significant, making communication between providers necessary. Because Medicare’s payment systems for Part A and Part B conflict, a lack of coordination can result in the denial of the Part B claim for outpatient therapy. Medicare Administrative Contractors heavily scrutinize claims for duplication of services, and poor documentation is a common reason for denial.
The patient has a responsibility to clearly communicate to both the Home Health Agency and the outpatient clinic that they are receiving concurrent services. Understanding the payment structure is also important, as the patient may be responsible for the Part B co-payment and deductible for the outpatient services. If the Part B claim is denied due to the Part A conflict, the patient could be responsible for the entire cost of the outpatient therapy unless a signed Advance Beneficiary Notice of Noncoverage (ABN) was obtained.