Outpatient Therapy Services

Transcription

1 Payment Policy: Outpatient Therapy Services Purpose: Commonwealth Care Alliance (CCA) reimburses contracted providers for medically necessary covered outpatient therapy s. Therapy s may include physical therapy (PT), occupational therapy (OT), speech therapy (SLP), and other similar s performed in a hospital outpatient setting. Original Date Approved: 3/23/18 Effective Date 6/1/18 Scope: Commonwealth Care Alliance (CCA) Product Lines: X All product lines Senior Care Options One Care Table of Contents: 1. Payment Policy Summary 2. Outpatient Therapy Services 3. Authorization Requirements 4. Reimbursement 5. Billing and Coding Guidelines 6. Audit and Disclaimer Information 7. References Date Revised: N/A PAYMENT POLICY SUMMARY Commonwealth Care Alliance (CCA) will reimburse physicians and other health care professionals for therapy s that are supported by medical necessity. This policy applies to all products, all network providers and other qualified health care professionals, including, but not limited to, authorized nonnetwork. CCA reimburses outpatient rehabilitation and therapeutic procedures that are designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functions that have been lost, impaired or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. OUTPATIENT THERAPY SERVICES Outpatient therapy s include three separate categories of s that aim to improve and restore function that a member has lost after an illness or injury. Physical Therapy (PT): Evaluation, treatment, and restoration to normal or best possible functioning or neuromuscular, musculoskeletal, cardiovascular, and respiratory systems. Occupational Therapy (OT): Evaluation and treatment of a member in his or her own environment for impaired physical functions. Speech-Language Pathology (SLP): Evaluation and treatment of speech, language, voice, hearing, fluency and swallowing disorders. Medicare/Medicaid covers outpatient therapy s if the member s need for therapy is documented in a written treatment plan developed by a therapist, a physician, or a non-physician provider (NPP) after consultation with a qualified therapist. A physician or non-physician provider (NPP) must certify 1

2 the care plan every 90 days. The prescribed course of therapy must be reasonable and necessary to treat the member s illness or injury. Covered therapy s must qualify as skilled therapy s that are appropriate for treatment of the patient s condition. AUTHORIZATION REQUIREMENTS There is no prior authorization requirements for PT, OT and SLP s. Providers are required to make sure Place of Service codes are placed on claims to indicate the setting in which a was provided. (Refer to most common list of codes under Billing and Coding Guidelines.) REIMBURSEMENT Reimbursement for outpatient PT/OT/SLP s is based on the Medicare/Medicaid Physician Fee Schedules and are subject to compliance with the following billing rules as well as other industry standards, such as CMS correct coding guidelines. CCA reimburses contracted providers for the following s: Initial evaluation for PT, OT and SLP Both the initial evaluation and therapy treatments rendered on the same day for the same member by the same provider PT treatment with one rate that includes all modalities rendered, per member, per date of OT treatment with one rate that includes all modalities rendered, per member, per date of SLP treatment with one rate that includes all modalities rendered, per member, per date of BILLING AND CODING GUIDELINES Industry coding is listed below, subject to codes being active on the date of. The American Medical Association (AMA), Centers for Medicare & Medicaid Services (CMS), and the U.S. Department of Health and Human Services may update codes more frequently or at different intervals than policy updates. The list of applicable codes may not be all inclusive. Revenue Codes: 0420 Physical Therapy General Classification 0421 Physical Therapy Visit 0424 Physical Therapy Evaluation or Re-evaluation 0429 Physical Therapy General Classification 0430 Occupational Therapy General Classification 0431 Occupational Therapy Visit 0434 Occupational Therapy Evaluation or Re-evaluation 2

3 0439 Occupational Therapy Other Occupational Therapy 0440 Speech-Language Pathology General Classification 0444 Speech-Language Pathology Evaluation or Re-evaluation 0449 Speech-Language Pathology Other Speech Therapy Therapy Modifiers: Therapy modifiers must be used as instructed by CMS GP Physical Therapy GO GN Occupational Therapy Speech Language Therapy CPT/HCPCS Coding: Physical Therapy evaluation; low complexity Physical Therapy evaluation; moderate complexity Physical Therapy evaluation; high complexity Physical Therapy re-evaluation Occupational Therapy evaluation; low complexity Occupational Therapy evaluation; moderate complexity Occupational Therapy evaluation; high complexity Occupational Therapy re-evaluation Evaluation of speech fluency Evaluation of speech sound production Evaluation of speech sound production; with evaluation of language comprehension and expression S9152 Speech therapy, re-evaluation Place of Service Codes: Most Common Place of Service Codes 19 Independent Clinic 3

4 21 Inpatient Hospital 22 On Campus-Outpatient Hospital 23 Emergency Room-Hospital 24 Ambulatory Surgical Center 49 Off Campus Outpatient Hospital Overview for Outpatient Therapy Functional Reporting: The Functional limitation reporting program is a CMS data collection project that supports payment with outcome based data and requires therapists to report functional limitation through a series of G- codes and severity modifiers in both the medical record and on the claim. CCA will return or reject claims for evaluation/re-evaluation therapy s without the correct functional information. The required G-codes and modifiers must be included on the claim to capture the member s functional limitations: At the onset of therapy episode At the minimum every 10 th visit At discharge There are 42 functional G-codes, 14 sets of three codes each. Six of the G-code sets generally describe PT and OT functional limitations, and eight sets of G-codes generally describe SLP functional limitations. (See Quick Reference Chart: Descriptors of G-codes and Modifiers) AUDIT AND DISCLAIMER INFORMATION As every claim is unique, the use of this policy is neither a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to member eligibility and benefits on the date of, coordination of benefits, referral/authorization and utilization management guidelines when applicable and adherence to plan policies and procedures and claims editing logic. CCA has the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this payment policy. If such an audit determines that your office/facility did not comply with this payment policy, CCA has the right to expect your office/facility to refund all payments related to non-compliance. 4

5 REFERENCES CMS Website: EOHHS Website: CMS Website: CCA Website: 5