Anthem Blue Cross and Blue Shield Central Region Clinical Claim Edit

Transcription

1 Subject: Established Evaluation and Management Services and Physical Therapy or Occupational Therapy Re-Evaluation with Physical Therapy Modalities or Therapeutic Procedures Edit# 076 Effective: 01/20/ /31/2099 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Description CODE RULE CODE Incidental Rationale Central Region Claim Edit#076 Page 1 of 8

2 Anthem Central Region bundles and as incidental with , - or Anthem does not routinely reimburse for physical therapy re-evaluation (97002) or occupational therapy re-evaluation (97004) when submitted with each session that PT or OT is performed. At each of the PT or OT sessions there s the usual pre-service and post-service work associated with this session that does not warrant submitting a PT re-evaluation or OT re-evaluation; unless a separate identifiable service was rendered. Therefore, if or is submitted with , - or only , - or reimburses. If on complaint, it is documented that a separate identifiable service was rendered such as a new assessment of the patient s symptoms, diagnostic re-evaluation or the functional status was required in order to revise the treatment plan then a PT or OT re-evaluation is submitted reimburses separately along with the PT or OT modalities. Claim Edit History 08/01/2014 Revised 01/20/2014 Revised 10/15/2009 Revised 09/09/2001 Adopted Central Region Claim Edit#076 Page 2 of 8

3 Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Established Evaluation and Management Services and Physical Therapy or Occupational Therapy Re-Evaluation with Physical Therapy Modalities or Therapeutic Procedures Edit: #76 Effective Date: 10/15/2009-1/19/2014 Status: Prior Last Review Date: 6/21/2006 Edit: Anthem Central Region is placing on a list of codes that no longer is reimbursable as of 10/15/ (Established, outpatient, evaluation and management services), (Physical therapy, reevaluation) or (Occupational therapy re-evaluation) bundles with (Supervised application of a modality), - (Constant attendance application of a modality) or (Therapeutic procedures) (Established, outpatient, evaluation and management services), (Physical therapy, reevaluation) or (Occupational therapy re-evaluation) does not bundle with (Supervised application of a modality), - (Constant attendance application of a modality) or (Therapeutic procedures) and does not bundle with (Supervised application of a modality), - (Constant attendance application of a modality) or (Therapeutic procedures). CODE RULE CODE Does not Reimburse see rationale below Incidental Central Region Claim Edit#076 Page 3 of 8

4 Separate Reimbursement Central Region Claim Edit#076 Page 4 of 8

5 Separate Reimbursement Central Region Claim Edit#076 Page 5 of 8

6 97546 Rationale for Edit: Anthem Central Region placed code on a list of codes that on longer reimburse. The effective date for no longer reimbursing is 10/15/2009. Anthem Central Region bundles , or as incidental with , - or Anthem does not routinely reimburse for established evaluation and management services ( ), physical therapy re-evaluation (97002) or occupational therapy re-evaluation (97004) when submitted with each session that PT or OT is performed. At each of the PT or OT sessions there are the usual pre-service and post-service work associated with this session that does not warrant submitting an established evaluation and management service, PT re-evaluation or OT re-evaluation; unless a separate identifiable service was rendered. Therefore if , or is submitted with , - or only , - or reimburses Anthem Central Region does not bundle with , - or When a separate identifiable service was rendered in addition to performing physician or occupational therapy, append modifier 25 to the evaluation and management service and both services reimburse separately. Anthem Central Region does not bundle or with , - or When a re-evaluation for assess the patient s progress or to modify physical or occupational therapy is required, append modifier 59 to the appropriate re-evaluation service ( ) for physical therapy reevaluation or ( ) for occupational therapy re-evaluation and both services reimburse separately. If on complaint, it is documented that a separate identifiable service was rendered such as a new assessment of the patient s symptoms, diagnostic re-evaluation or the function statues was required in order to revise the treatment plan then an evaluation and management, PT or OT re-evaluation is submitted and reimburses separately along with PT or OT modalities. References: 1. Centers for Medicare and Medicaid (April 1, 2006-June 30, 2006) National Correct Coding Initiative Edits-Version Retrieved May 22, 2006 from the World Wide Web: DID=-99&sortByDID=2&sortOrder=ascending&itemID=CMS Prior Version(s), if any, of this edit can be found below Central Region Claim Edit#076 Page 6 of 8

7 Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Subject: Established Evaluation and Management Services and Physical Therapy or Occupational Therapy Re- Evaluation with Physical Therapy Modalities or Therapeutic Procedures Edit #: 076 Effective Date: 09/09/ /14/2009 Status: Prior Last Review Date: 05/10/2001 Edit (Established, outpatient, evaluation and management services), (Physical therapy, reevaluation) or (Occupational therapy re-evaluation) bundles with (Supervised application of a modality), - (Constant attendance application of a modality) or (Therapeutic procedures). CODE RULE CODE Incidental Central Region Claim Edit#076 Page 7 of 8

8 Rationale for Edit: Anthem Central Region bundles , or as incidental with , - or Anthem does not routinely reimburse for establish evaluation and management services ( ), physical therapy re-evaluation (97002) or occupational therapy re-evaluation (97004) when submitted with each session that PT or OT is performed. At each of the PT or OT sessions there s the usual preservice and post-service work associated with this session that does not warrant submitting an established evaluation and management service, PT re-evaluation or OT re-evaluation; unless a separate identifiable service was rendered. Therefore, if , or is submitted with , - or only , - or reimburses. If on complaint, it is document that a separate identifiable service was rendered such as a new assessment of the patient s symptoms, diagnostic re-evaluation or the functional status was required in order to revise the treatment plan then an evaluation and management, PT or OT re-evaluation is submitted reimburses separately along with the PT or OT modalities. Central Region Claim Edit#076 Page 8 of 8