Article for Outpatient Physical and Occupational Therapy Services Supplemental Instructions Article (A50612)

Transcription

1 Article for Outpatient Physical and Occupational Therapy Services Supplemental Instructions Article (A50612) Contractor Information Contractor Name National Government Services, Inc. Contractor Number Number Type State(s) FI IN FI IL FI KY FI OH FI WI FI MI Carrier IN MAC CT Part A MAC CT Part B MAC NY Part A MAC NY Part B MAC NY Part B MAC NY Part B Contractor Type Carrier Fiscal Intermediary MAC Part A MAC- Part B Article Information

2 Article ID Number A50612 Article Type Article Key Article Yes Article Title Outpatient Physical and Occupational Therapy Services Supplemental Instructions Article AMA CPT / ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Primary Geographic Jurisdiction Number Type State(s) FI IN FI IL FI KY FI OH FI WI FI MI Carrier IN MAC CT Part A MAC CT Part B MAC NY Part A MAC NY Part B MAC NY Part B MAC NY Part B

3 Original Article Effective Date 07/01/2008 Article Revision Effective Date 07/01/2011 Article Text The information in this Supplemental Instructions Article (SIA) contains coding or other guidelines that complement the Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services. The LCD can be accessed through our contractor Web site at It can also be found on the Medicare Coverage Database at Coding Guidelines: Unless otherwise specified, italicized text represents quotation from one or more of the CMS sources listed in the Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services or CMS Publication , Claims Processing Manual, Chapter 30. General Guidelines for claims submitted to Carriers or Intermediaries or Part A or Part B MAC: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-9-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication , Medicare Claims Processing Manual, Chapter 30, for complete instructions. Effective from April 1, 2010, non-covered services should be billed with modifier GA, - GX, -GY, or GZ, as appropriate. The GA modifier ( Waiver of Liability Statement Issued as Required by Payer Policy ) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act.

4 Effective April 1, 2010, Fiscal Intermediary (FI) and Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that

5 is a compelling reason. For example, when a patient with diabetes is being treated for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment). Where it is possible in accordance with State and local laws and the contractors Local Coverage Determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/npp must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position. Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code. Non-covered services When billing for any of the following non-covered procedures, report CPT code and enter the appropriate name from the list below in item 19 or the electronic equivalent on the claim: Non-surgical spinal decompression devices: this is considered noncovered due to lack of medical literature supporting the effectiveness of this therapy and should be billed with modifier GA or GZ, as appropriate. Low level/cold laser light therapy (LLLT): Low level/cold laser light therapy (LLLT) is considered not reasonable and necessary under SSA 1862(a)(1)(A) and is not payable by Medicare. This procedure is considered non-covered billed under any HCPCS/CPT codes, including S8948 (for Part A claims) and and should be billed with modifier GA or GZ, as appropriate. Frequency Specific Microcurrent: this is considered non-covered due to lack of medical literature supporting the effectiveness of this therapy and should be billed with modifier GA or GZ, as appropriate. Whole body periodic acceleration: this service does not meet the benefit requirement that it requires the services of a skilled professional and should be billed with modifier GY. Light beam generator therapy: this is considered non-covered due to lack of medical literature supporting the effectiveness of this therapy and should be billed with modifier GA or GZ, as appropriate. The appropriate modifier for non-covered services, as described in the Advance Beneficiary Notice of Noncoverage section of this article, should be listed on the claim. Unlisted Procedure Codes: If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. When reporting such a service, the appropriate unlisted code may be used to indicate the service. When unlisted codes are used, the provider/supplier must define the service in the Remarks section of the claim form (item 19 for CMS 1500 and FL 80 for the UB-04.) Defining the following services in the Remarks section of the claim will facilitate pricing for the following services: Specify modality type, time of constant attendance required. In

6 addition, refer to the Non-covered services" section above Specify the clinical services furnished Specify the physical medicine or rehabilitation service provided and the time expended The use of unlisted codes should be rare. If unlisted codes are billed, the medical record must clearly state what modality or procedure is billed as an unlisted code, why the specific and unique skills of a therapist are required to provide the services, the length of direct contact time involved in delivering the service, and the anticipated benefit from the service. If such detail is not included in the medical record, the unlisted code billed will be subject to denial as not medically necessary. Therapy Cap Exception Process Effective January 1, 2006, a financial limitation (therapy cap) was placed on outpatient rehabilitation services received by Medicare beneficiaries. These limits apply to outpatient Part B therapy services from all settings except the outpatient hospital (place of service code 22 on carrier or Part B MAC claims) and the hospital emergency room (place of service code 23 on carrier or Part B MAC claims). These excluded hospital services are reported on types of bill 12x or 13x on intermediary or Part A MAC claims. The annual limit on the allowed amount is combined for outpatient physical therapy and speech-language pathology, with a separate amount for occupational therapy. A process to allow for exceptions to the caps has been established in cases where continued therapy services are medically necessary. Exceptions to caps based on the medical necessity of the service are in effect only when Congress legislates the exceptions. References to the exceptions process apply only when the exceptions are in effect. The KX modifier is added to claim lines to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record. For further therapy cap information, review CMS publication , Medicare Claims Processing Manual, chapter 5, section Canalith repositioning procedure (CPT code 95992) This procedure is covered as a single service per day, regardless of the duration required to provide the service or the number of repeat services. When provided during the same encounter as an E&M service, subsequent to the diagnosis of and first encounter for the BPPV, a significant and separately identifiable reason supporting the E&M service should be present. Refer to the LCD for Physical Medicine and Rehabilitation (L26884) for billing guidelines on specific services. For claims submitted to the carrier or Part B MAC: All services/procedures performed on the same day for the same beneficiary by the physician/provider should be billed on the same claim. Coverage of outpatient physical therapy and occupational therapy under Part B includes the services of a qualified therapist in private practice when furnished in the therapist s office or the beneficiary s home. For this purpose, home includes an institution that is used as a home, but not a hospital, CAH or SNF, (Federal Register, Vol 63, No. 211, pg , Nov. 2, 1998). Claims for outpatient physical and occupational therapy services are payable under Medicare Part B in the following places of service: school (03), only if residential,

7 homeless shelter (04), office (11), home (12), other than a facility that is a private residence, assisted living facility (13), temporary lodging (16), group home (14), urgent care (20), custodial care facility (33), Independent Clinic (49). For claims submitted to the fiscal intermediary or Part A MAC: Hospital Inpatient Claims: The hospital should report the patient's principal diagnosis in Form Locator (FL) 67 of the UB-04. The principal diagnosis is the condition established after study to be chiefly responsible for this admission. The hospital enters ICD-9-CM codes for up to eight additional conditions in FLs 67A-67Q if they co-existed at the time of admission or developed subsequently, and which had an effect upon the treatment or the length of stay. It may not duplicate the principal diagnosis listed in FL 67. For inpatient hospital claims, the admitting diagnosis is required and should be recorded in FL 69. (See CMS Publication , Medicare Claims Processing Manual, Chapter 25, Section 75 for additional instructions.) Hospital Outpatient Claims: The hospital should report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in FL 67. If no definitive diagnosis is made during the outpatient evaluation, the patient s symptom is reported. If the patient arrives without a referring diagnosis, symptom or complaint, the provider should report an ICD-9-CM code for Persons Without Reported Diagnosis Encountered During Examination and Investigation of Individuals and Populations (V70-V82). The hospital enters the full ICD-9-CM codes in FLs 67A-67Q for up to eight other diagnoses that co-existed in addition to the diagnosis reported in FL 67. Coding Information Bill Type Codes: Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims. 012x 013x 022x Hospital Inpatient (Medicare Part B only) Hospital Outpatient Skilled Nursing - Inpatient (Medicare Part B

8 only) 023x 034x 074x 075x 085x Skilled Nursing - Outpatient Home Health - Other (for medical and surgical services not under a plan of treatment) Clinic - Outpatient Rehabilitation Facility (ORF) Clinic - Comprehensive Outpatient Rehabilitation Facility (CORF) Critical Access Hospital Revenue Codes: Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the article services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes. Revenue codes only apply to providers who bill these services to the fiscal intermediary or Part A MAC. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier or Part B MAC. Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes Physical Therapy - General Classification 0421 Physical Therapy - Visit 0424 Physical Therapy - Evaluation or Re-evaluation 0429 Physical Therapy - Other Physical Therapy 0430 Occupational Therapy - General Classification 0431 Occupational Therapy - Visit 0434 Occupational Therapy - Evaluation or Reevaluation 0439 Occupational Therapy - Other Occupational

9 Therapy CPT/HCPCS Codes For most revenue codes, Outpatient Prospective Payment System (OPPS) requirements mandate HCPCS coding on the claim. When the revenue code you are reporting requires HCPCS coding, choose the appropriate code(s) from the list below when submitting your claim to Medicare: This list represents services that are commonly performed by physical and occupational therapists and is not all-inclusive Application of long arm cast Application of forearm cast Apply hand/wrist cast Apply finger cast Apply long arm splint Apply forearm splint Apply forearm splint Application of finger splint Application of finger splint Strapping of chest Strapping of shoulder Strapping of elbow or wrist Strapping of hand or finger Application of long leg cast Application of long leg cast Application of long leg cast Apply short leg cast Apply short leg cast Apply rigid leg cast Application long leg splint

10 29515 Application lower leg splint Strapping of hip Strapping of knee Strapping of ankle and/or ft Strapping of toes Application of paste boot Application of foot splint Biofeedback train any meth Biofeedback peri/uro/rectal Limb muscle testing manual Hand muscle testing manual Body muscle testing manual Body muscle testing manual Range of motion measurements Range of motion measurements Canalith repositioning procedure(s), (eg, Epley maneuver, Semont maneuver), per day Cognitive test by hc pro Pt evaluation Pt re-evaluation Ot evaluation Ot re-evaluation Hot or cold packs therapy Mechanical traction therapy Vasopneumatic device therapy Paraffin bath therapy Whirlpool therapy Diathermy eg microwave

11 97026 Infrared therapy Ultraviolet therapy Electrical stimulation Electric current therapy Contrast bath therapy Ultrasound therapy Hydrotherapy Physical therapy treatment Therapeutic exercises Neuromuscular reeducation Aquatic therapy/exercises Gait training therapy Massage therapy Physical medicine procedure Manual therapy Group therapeutic procedures Therapeutic activities Cognitive skills development Sensory integration Self care mngment training Community/work reintegration Wheelchair mngment training Rmvl devital tis 20 cm/< Rmvl devital tis addl 20 cm< Wound(s) care non-selective Neg press wound tx < 50 cm Neg press wound tx > 50 cm Physical performance test

12 97755 Assistive technology assess Orthotic mgmt and training Prosthetic training C/o for orthotic/prosth use Physical medicine procedure G0281 G0283 G0295 G0329 Elec stim unattend for press Elec stim other than wound Electromagnetic therapy onc Electromagntic tx for ulcers ICD-9 Codes that are Covered Please see LCD ICD-9 Codes that are Not Covered Please see LCD Other Information Other Comments These supplemental instructions apply within states outside the primary geographic jurisdiction with facilities that have nominated National Government Services to process their claims. Revision History Explanation Article Published July 2011: the existing LCD and SIA were resubmitted to all NGS Part A and Part B jurisdictions for public and CAC comment from 01/13/ /26/2011. Billing instructions were added for billing noncovered services, Frequency specific microcurrent, Whole body periodic acceleration, and Light beam generator therapy. Billing guidelines were added for Canalith repositioning procedure (CPT code 95992) and the CPT was added to the list of HCPCS codes. HCPCS code G0295 (non-covered) was also added to the list of HCPCS codes. Article number A49932 was retired and replaced by article number A50612 effective July 1, Other formatting

13 changes were made in the article. Article published December 2010: The LCD and SIA were revised to delete coding instructions that required ICD-9-CM codes V57.1-V57.89 to be included as the primary diagnosis on all therapy claims (retroactive to 11/01/2010). Furthermore, NGS will not require these diagnosis codes whether as primary or subsequent codes. NGS does, however, note that such a recommendation does exist in the ICD-9-CM manual. If providers use these codes, they must also include the diagnosis code of the specific medical condition for which each therapy service was provided. Bill type 11x removed. Article published November 2010: The existing LCD and SIA were resubmitted to all NGS Part A and Part B jurisdictions for public and CAC comment from 5/10/2010 6/23/2010. Changes made are: Bill type 11x added; Guidelines added for reporting non-surgical spinal decompression devices for denial purposes, with CPT code 97039; Removed instruction to bill low back strapping with CPT code as this has been identified as an obsolete service; In response to a reconsideration request, instructions for reporting ICD-9 codes were revised to indicate that a specific code to identify the type of therapy provided be listed as the primary diagnosis on the claim, with the conditions necessitating the therapy service(s) reported as secondary diagnoses. Article A46198 is retired and is superseded by article A49932, effective 11/01/2010. Article published June 2010: Limitation of liability guidelines revised in accordance with CMS Transmittals 1840 and Minor formatting changes made. Article published January, 2010: Deletion of CPT code (Strapping; Low Back) with directions to use unlisted code to indicate low back strapping in CPT Addition of the following section: Unlisted Procedure Codes: If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. When reporting such a service, the appropriate unlisted code may be used to indicate the service. When unlisted codes are used, the provider/supplier must define the service in the Remarks section of the claim form (item 19 for CMS 1500 and FL 80 for the UB-04.) Defining the following services in the Remarks section of the claim will facilitate pricing for the following services: Strapping; low back Specify modality type, time of constant attendance required (NOTE: Low level/cold laser light therapy (LLLT) is considered not reasonable and necessary under SSA 1862(a)(1)(A) and is not payable by Medicare. This procedure is considered non-covered billed under any HCPCS/CPT codes, including S8948 and ) Specify the clinical services furnished Specify the physical medicine or rehabilitation service provided and the time expended The use of unlisted codes should be rare. If unlisted codes are

14 billed, the medical record must clearly state what modality or procedure is billed as an unlisted code, why the specific and unique skills of a therapist are required to provide the services, the length of direct contact time involved in delivering the service, and the anticipated benefit from the service. If such detail is not included in the medical record, the unlisted code billed will be subject to denial as not medically necessary. Article published August 2009: Source of revision Internal Place of service temporary lodging (16) and urgent care facility (20) added as payable under Medicare Part B. Place of service nursing facility (32) removed for the Part B guidelines per SNF consolidated billing. Added to section ICD-9-Codes that are Not Covered, Please see LCD. Minor changes were made to reflect current template language. 06/05/ In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number was removed from this Article as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states. 05/15/ In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers and were removed from this Article as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states. Article published March 2009: Source of revision Internal Minor changes made to reflect current template language. This SIA was revised to add the Jurisdiction 13 (J-13) MAC contractor numbers. This revised Supplemental Instructions Article (SIA) is effective for all National Government Services jurisdictions on July 18, 2008 with these exceptions: for Connecticut Part B the SIA is effective on August 1, 2008; for Upstate New York Part B, the SIA is effective on September 1, 2008; and for New York and Connecticut Part A, the SIA is effective on November 14, For New York Part A (contract 00308), the content of this SIA is currently in effect but the SIA will be transferred to the J-13 contract number on

15 November 14, /14/ In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number is removed from this article. Effective on this date, claims processing for Delaware is performed by Highmark Medicare Services, the Part A/Part B MAC contractor for this state, and the claims processing for New York and Connecticut is performed by National Government Services under the J-13 MAC contract; carrier number is removed, and claims processing for New Jersey is performed by Highmark Medicare Services, the Part A/Part B MAC contractor for this state. 05/15/ In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary numbers and were removed from this Article as the claims processing for Maine and Massachusetts was transitioned to NHIC, the Part A/Part B MAC contractor in these states. 06/05/ In accordance with Section 911 of the Medicare Modernization Act of 2003, fiscal intermediary number was removed from this article as the claims processing for New Hampshire and Vermont was transitioned to NHIC, the Part A/Part B MAC contractor in these states. 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was

16 11/15/ The description for CPT/HCPCS code was 11/15/ The description for CPT/HCPCS code was 11/15/ CPT/HCPCS code was deleted from group 1 8/1/ The description for Bill Type Code 11 was changed 8/1/ The description for Bill Type Code 12 was changed 8/1/ The description for Bill Type Code 13 was changed 8/1/ The description for Bill Type Code 22 was changed 8/1/ The description for Bill Type Code 23 was changed 8/1/ The description for Bill Type Code 34 was changed 8/1/ The description for Bill Type Code 74 was changed 8/1/ The description for Bill Type Code 75 was changed 8/1/ The description for Bill Type Code 85 was changed 8/1/ The description for Revenue code 0420 was changed 8/1/ The description for Revenue code 0421 was changed 8/1/ The description for Revenue code 0424 was changed 8/1/ The description for Revenue code 0429 was changed 8/1/ The description for Revenue code 0430 was changed 8/1/ The description for Revenue code 0431 was changed 8/1/ The description for Revenue code 0434 was changed 8/1/ The description for Revenue code 0439 was changed 11/21/ For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this article, there may not be any change in how the code displays in the document: descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group descriptor was changed in Group 1 Related Documents

17 LCD(s) L Outpatient Physical and Occupational Therapy Services Last Modified: 7/13/11