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G98

Therapy Services
Published January 2012

Part B

  IMPORTANT  
Note: This manual was previously titled Physical Medicine and Rehabilitation.

The information provided in this manual was current as of December 2011. Any changes or new information superseding the information in this manual, provided in newsletters/eBulletins, MLN articles, listserv notices, Local Coverage Determinations (LCDs) or CMS Internet-Only Manuals with publication dates after December 2011, are available at: http://www.trailblazerhealth.com/Medicare.aspx

© CPT codes, descriptions, and other data only are copyright 2011 American Medical Association. All rights reserved. Applicable FARS/DFARS clauses apply. © CDT codes and descriptions are copyright 2011 American Dental Association. All rights reserved. Applicable FARS/DFARS clauses apply.

Provider Outreach and Education GA © 2012 TrailBlazer Health Enterprises®/TrailBlazer®. All rights reserved.

  IMPORTANT  

MEDICARE PART B
Therapy Services

Table of Contents
OVERVIEW..................................................................................................................... 1 DEFINITION OF TERMS ................................................................................................ 2 Rehabilitation Services ................................................................................................ 2 Active Participation ...................................................................................................... 3 Assessment ................................................................................................................. 3 Certification.................................................................................................................. 3 Clinician ....................................................................................................................... 3 Complexities ................................................................................................................ 3 Date ............................................................................................................................. 4 Episode of Outpatient Therapy .................................................................................... 4 Evaluation.................................................................................................................... 4 Re-Evaluation .............................................................................................................. 4 Interval......................................................................................................................... 5 Non-Physician Practitioner (NPP)................................................................................ 5 Physician ..................................................................................................................... 5 Patient ......................................................................................................................... 5 Providers ..................................................................................................................... 5 Qualified Professional.................................................................................................. 6 Qualified Personnel ..................................................................................................... 6 Signature Guidelines for Medical Review Purposes .................................................... 6 Supervision Levels....................................................................................................... 7 Suppliers...................................................................................................................... 7 Therapist...................................................................................................................... 7 Therapy ....................................................................................................................... 8 Treatment Day ............................................................................................................. 8 Visits or Treatment Sessions ....................................................................................... 8 ‘Incident to’ .................................................................................................................. 8 Direct Supervision in the Office ................................................................................... 9 Supervised Procedure ............................................................................................... 10 Constant Attendance ................................................................................................. 10 Not Covered .............................................................................................................. 10 Not Medically Necessary ........................................................................................... 10 PROFESSIONAL QUALIFICATION REQUIREMENTS ............................................... 11 Physician ................................................................................................................... 11 Nurse Practitioner (NP).............................................................................................. 11 Clinical Nurse Specialist (CNS) ................................................................................. 11 Collaboration ............................................................................................................. 12 Physician Assistant (PA)............................................................................................ 12 Physical Therapist (PT) ............................................................................................. 13 Physical Therapist Assistant (PTA)............................................................................ 14

Rev. 01/2012

i

Contents

.............................................................................................................. Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs)..... 20 MEDICARE ENROLLMENT OF THERAPISTS IN PRIVATE PRACTICE (TPPS)............................................................................ 30 PHYSICAL THERAPY PERFORMED BY A PHYSICIAN/NON-PHYSICIAN PRACTITIONER (NPP)............................................................................................................ 42 Denials Due to Certification ........... 34 Outpatient Therapy Must Be Under the Care of a Physician/Non-Physician Practitioner (NPP) (Orders/Referrals and Need for Care).......... 32 Non-Physician Practitioners (NPPs)....... 35 Establishing the Plan ........................................................................................ 31 Claim Form Requirements............................................................................................................... 21 Therapists in a Physician Group ................................................................................................................. 26 Application of Medicare Guidelines to Occupational Therapy Services ..... 43 Rev............................................................................................................................................................ 39 Delayed Certification......................................................................................... 33 CONDITIONS OF COVERAGE ......................................................................................................................... 32 Physical Medicine and Rehabilitation Denial Reasons ................................................................................................................................................ Physician Assistants (Pas)............................................................. 31 Physical Medicine and Rehabilitation (PM&R)............................ 26 Occupational Therapy......................................... 01/2012 ii Contents .................... 25 Coverage Criteria....................................................................... 32 Fee Schedule ............................. 24 THERAPY PERFORMED BY LICENSED THERAPISTS IN PRIVATE PRACTICE ........................ 31 Coverage Requirements....... 23 ‘Incident to’ Services for Physical Therapist Assistants (PTAs) and Occupational Therapist Assistants (OTAs)..... 23 Assignment................................................... 16 Occupational Therapist Assistant (OTA).......................................................... 26 Supplies. 21 Services Furnished by a TPP ....... 25 Reimbursement ........ 19 Speech-Language Pathologist Assistants (SLPAs) ..................................................................................................... 25 Supervision.............................. 28 Physical Medicine and Rehabilitation Denial Reasons ............................................................................................. 24 Services of Speech-Language Pathology Support Personnel .............................................................. 35 Certification and Recertification ..................... 31 Reimbursement ............................................................................................................................................................................................................................................... 27 Practice of Speech-Language Pathology......................................... 17 Speech-Language Pathologist (SLP)................................... 32 ‘Incident to’ Related to Physical/Occupational Therapy by Physicians and NonPhysician Practitioners (NPPs) ...................................................................................................................................................................................................................................................................................................................................MEDICARE PART B Therapy Services Occupational Therapist (OT) .................................................................................................................................................. 25 Aides............................................................................. 34 Documentation ...............................................................................

.................................................................................. 69 Exceptions to Therapy Caps................ 49 Evaluation. 45 EVALUATION/RE-EVALUATION AND PLAN OF CARE ........................................................................................................................................ 45 Documentation Required ................................................................................................................................................................................................................. 76 Provider Notification for Beneficiaries Exceeding Therapy Limits...... 70 Automatic Process Exceptions ................................................................................................................................................................................ 87 Evaluations ..................................................................................................................................................................................................................................................................................................................................................................................................................................... 88 Specific Modality Guidelines.................................................................................................................................... 61 TrailBlazer’s Utilization Guidelines.................... 80 Evaluation and Management (E/M) .................... 83 INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY .......................................... 68 Outpatient Therapy Caps...... 01/2012 iii Contents ............................. 80 Advance Beneficiary Notice of Noncoverage (ABN) ..................... 49 Re-Evaluations ................................................................................................................. 74 KX Modifier for Therapy Cap Exceptions............. 61 Timed and Untimed Codes ...................................................... 104 Rev...................... 71 Additional Considerations for Exceptions .............. 93 Utilization Guidelines .... 84 General Physical Medicine and Rehabilitation (PM&R) Guidelines .............................................................................................................................................................. 74 Progressive Corrective Action (PCA) and Medical Review......................................................................................................... 78 MODIFIERS ................................. 73 Appeals..... 89 General Guidelines for Therapeutic Procedures (97110–97546) ....................................................................................................... 80 Introduction..................................................................................................... 83 Miscellaneous ................................................. 82 Proper Use of the 59 Modifier ..................................................................................................................................................................................... 53 REPORTING UNITS OF SERVICE...................................................................................................................................................... 66 THE FINANCIAL LIMITATION (THERAPY CAP) ......................................................................................................... 68 Overview................... 80 Additional HCPCS Codes .......................................MEDICARE PART B Therapy Services GENERAL DOCUMENTATION ............................................................................................................................................. 81 National Correct Coding Initiative (NCCI) ................... 71 Exceptions for Evaluation Services............................................................................................. 76 Advance Beneficiary Notice of Noncoverage (ABN) ................................................ 82 MEDICALLY UNLIKELY EDITS (MUEs) .................................................................................. 84 Maintenance Therapy ......................................................... 66 Determining What Time Counts Toward 15-Minute Timed Codes – All Claims ..................................................... 52 Progress Report....................................... 80 Therapy Modifiers ........

.............................. 113 TrailBlazer LCDs................... 113 National Correct Coding Initiative (NCCI) .....................MEDICARE PART B Therapy Services MULTIPLE PROCEDURE PAYMENT REDUCTION (MPPR) FOR SELECTED THERAPY SERVICES ............................................................................................................................ 109 FEE SCHEDULE CHANGES........................... 113 Home Health Prospective Payment System (HH PPS) ... 109 Background ............................ 111 RESOURCES ............................................................................... 112 CMS Internet-Only Manual (IOM) .................................................................................................................................................................................................................................................................................................. 113 Advance Beneficiary Notice of Noncoverage (ABN) ................................................................................................................................... 114 Rev........................................ 109 Policy .................................................................................................. 112 ADDITIONAL RESOURCES THAT APPLY TO THERAPY SERVICES ........ 113 REVISION HISTORY ........... 01/2012 iv Contents ...............................................................

Rev. Non-Physician Practitioners (NPPs) and/or independent physical and occupational therapists in home and office settings.MEDICARE PART B Therapy Services OVERVIEW The information in this manual defines the coverage under Medicare Part B for outpatient physical therapy. 01/2012 1 Overview . Note: Independent physical and occupational therapists are limited to the home or office setting. occupational therapy and speech-language pathology services provided by physicians.

. physical therapy.  There must be an expectation that the patient’s condition will improve significantly in a reasonable and generally predictable period of time. To determine coverage. reevaluation and assessment documented in the progress report should describe objective measurements which. when possible. (also known as a plan of care or plan of treatment) must be established before treatment begins. evaluation.  Services that do not require the performance or supervision of a physical therapist are not considered reasonable or necessary physical therapy services. the following conditions must be met:  The services must be considered under accepted standards of medical practice to be a specific and effective treatment for the patient’s condition. or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state.MEDICARE PART B Therapy Services DEFINITION OF TERMS Rehabilitation Services Rehabilitative therapy includes recovery or improvement in function and. 01/2012 2 Definition of Terms . Services related to activities for the general good and welfare of patients (general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation) do not constitute therapy services for Medicare purposes. written or dictated). The plan. occupational therapy or speech-language pathology services must relate directly and specifically to an active written treatment plan. The physician. Therefore.  The amount. show improvements in function or decrease in severity or rationalization for an optimistic outlook to justify continued treatment. The plan is established when it is developed (e. frequency and duration of the services must be reasonable.g. restoration to a previous level of health and well-being. To be considered reasonable and medically necessary. Rev. Non-Physician Practitioner (NPP) or the qualified therapist providing such services may establish a plan of treatment for outpatient physical therapy.  The services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified physical therapist or occupational therapist under the therapist’s supervision. occupational therapy or speech-language pathology services. even if they are performed or supervised by a physical therapist. when compared. The treatment must be reasonable and necessary for the individual’s illness or injury.

state and local laws allow it. severity. assistive technology assess. Based on these assessment data. Complexities Complexities are complicating factors that may influence treatment.MEDICARE PART B Therapy Services Active Participation Active participation of the clinician in treatment means that the clinician personally furnishes in its entirety at least one billable service on at least one day of treatment Assessment Assessments shall be provided only by clinicians. intensity and/or duration of treatment. Services that require the skills of a therapist may be appropriately furnished by clinicians. 97755©. Complexities may be represented by diagnoses (ICD-9-CM codes). acuity. that is. which may be payable). NPP or a therapist (but not to an assistant. Rev. the professional may make judgments about progress toward goals and/or determine that a more complete evaluation or reevaluation is indicated. or the patient’s social circumstances. Clinician Clinician is a term used in this manual to refer to only a physician. e. and their personal professional training is judged by Medicare contractors as sufficient to provide to the beneficiary skills equivalent to a therapist for that service. because assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient’s condition(s). Clinicians make clinical judgments and are responsible for all services they are permitted to supervise.g. such as the support of a significant other or the availability of transportation to therapy. Certification Certification is the physician’s/NPP’s approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.. aide or any other personnel) providing a service within his scope of practice and consistent with state and local law.g. patient factors such as age. by or under the supervision of qualified physicians/NPPs when their scope of practice. frequency. Assessment determines changes in the patient’s status since the last visit/treatment day and whether the planned procedure or service should be modified. 01/2012 3 Definition of Terms . Routine weekly assessments of expected progression in accordance with the plan are not payable as re-evaluations. multiple conditions and motivation. The assessment is separate from evaluation and is included in services or procedures (it is not separately payable). The term assessment as used in Medicare manuals related to therapy service is distinguished from language in CPT codes that specify assessment (e.. they may influence the type.

e. after the initial treatment session. the beneficiary may be treated for more than one condition including conditions with an onset after the episode has begun. staff may add “Received Date” in writing or with a stamp. as long as the dates are accurate. If that same patient developed a swallowing problem during intubation for the hip surgery. If they are different.g. in calendar days. Also. If services provided on one date are documented on another date. both dates should be documented. Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a Rev. if a physician certifies a plan and fails to date it. Evaluation Evaluation is a separately payable comprehensive service provided by a clinician that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. including goals and the selection of interventions. Re-Evaluation A re-evaluation provides additional objective information not included in other documentation. an outpatient therapy episode is defined as the period of time. 01/2012 4 Definition of Terms . develops low-back pain would also be treated under a physical therapy plan of care for rehabilitation of low-back pain. These evaluative judgments are essential to development of the plan of care.. The date may be added to the record in any manner and at any time. a beneficiary receiving physical therapy for a hip fracture who. Episode of Outpatient Therapy For the purposes of therapy policy..MEDICARE PART B Therapy Services Date A date may be in any form (written. stamped or electronic). certification or recertification and forgets to date it. For example. if the physician faxes the referral. for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (physical therapy. the date that prints on the fax is valid. from the first day the patient is under the care of the clinician (e. For example. the first day of treatment by the speech-language pathologist would be a new episode of speech-language pathology care. During the episode. or it may be a separate plan specific to the low-back pain. for a new diagnosis or when a condition is treated in a new setting. refer to both the date a service was performed and the date the entry to the record was made. occupational therapy or speech-language pathology) until the last date of service for that plan of care for that discipline in that setting. That plan may be modified from the initial plan. but treatment for both conditions concurrently would be considered the same episode of physical therapy treatment.g. The received date is valid for certification/recertification purposes. Evaluation is warranted.

” “resident” and “beneficiary” are terms used interchangeably to indicate enrolled recipients of Medicare-covered services. DPM) and/or NPPs (physician’s assistant.  Physical therapists. A physician/NPP may certify a plan of care for an interval length that is less than 90 days. participating clinics. rehabilitation Rev. podiatric medicine or optometry (for low-vision rehabilitation only). Comprehensive Outpatient Rehabilitation Facilities (CORFs). hospices. Physician A physician with respect to outpatient rehabilitation therapy services means a doctor of medicine. There may be more than one certification interval in an episode of care. Although some state regulations and state practice acts require re-evaluation at specific times.” “client. The certification interval is not the same as a Progress Report period. occupational therapists. Patient “Patient. certify or supervise therapy services. speech-language pathologists. provide. Non-Physician Practitioner (NPP) NPP means physician assistants. for Medicare payment. nurse practitioner). Home Health Agencies (HHAs). if state and local laws permit it and when appropriate rules are followed. osteopathy (including an osteopathic practitioner). DO. The decision to provide a re-evaluation shall be made by a clinician. 01/2012 5 Definition of Terms .MEDICARE PART B Therapy Services significant improvement or decline or change in the patient’s condition or functional status that was not anticipated in the plan of care for that interval. Skilled Nursing Facilities (SNFs). Critical Access Hospitals (CAHs). Providers Qualified professionals include the following who are licensed or certified by the state to perform therapy services and who also may perform therapy services under Medicare:  Physicians (MD. based on an individual’s needs. Providers of services include the following and are used to define a facility (not a person who provides a service):  Participating hospitals. clinical nurse specialists and nurse practitioners who may. clinical nurse specialist. Interval Interval of certified treatment (certification interval) consists of 90 calendar days or less. re-evaluations must also meet Medicare coverage guidelines. Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.

Signature Log A signature log includes the typed or printed name and usual signature of the author associated with initials or an illegible signature. community mental health centers with agreements only to furnish partial hospitalization services. Public health agencies with agreements to furnish outpatient therapy services. speechlanguage pathologist. from the provider(s) who renders the service or certifies the services. 01/2012 6 Definition of Terms . The signature log may be submitted when records are requested. Signature Guidelines for Medical Review Purposes Medicare requires that services provided/ordered be authenticated by the author. Stamped signatures are not acceptable. nurse practitioner. including credentials. Qualified personnel may or may not be licensed as therapists but meet all of the requirements for therapists with the exception of licensure.MEDICARE PART B Therapy Services  agencies or Outpatient Rehabilitation Facilities (ORFs). Therapy documentation must have legible signatures. Signature Authentication Process If the signature is found to be illegible or missing from the medical documentation. physician. The method used must be a handwritten or electronic signature. Qualified Professional A qualified professional means a physical therapist. occupational therapist. Assistants are limited in the services they may provide and may not supervise others. Qualified Personnel Qualified personnel means staffs (auxiliary personnel) that have been educated and trained as therapists and qualify to furnish therapy services only under the direct supervision “incident to” a physician or NPP. Qualified professionals may also include Physical Therapist Assistants (PTAs) and Occupational Therapy Assistants (OTAs) when working under the supervision of a qualified therapist within the scope of practice allowed by state law. The signature log may be included on the actual page where the initials or illegible signatures are used or it may be a separate document. clinical nurse specialist or physician’s assistant who is licensed or certified by the state to perform therapy services and who also may appropriately perform therapy services under Medicare policies. a signature log or attestation statement to determine the identity of the author may be requested by the reviewer before the claim is processed. Rev.

Suppliers Suppliers of therapy services include individual practitioners such as physicians. Rev.  General supervision (physician/NPP is available but not necessarily on the premises). the levels include:  Personal supervision (in the room).  Direct supervision (in the office suite). Providers should not add late signatures to the medical record. but make use of the signature authentication process. 01/2012 7 Definition of Terms . additional documentation (attestation statement or signature log) may need to be submitted with your medical records.cms.150–163. To meet the requirements for signatures. a sample attestation statement and a chart with examples of acceptable and unacceptable legible signatures.60 I(1).MEDICARE PART B Therapy Services Attestation Statement An attestation statement is required when a signature is missing from the documentation. When medical records are requested. An attestation is specific to the service documented. Depending on the setting.701–729 and 486. NPPs. To view all signature requirements. it must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary and date of service.pdf Supervision Levels Supervision levels for outpatient rehabilitation therapy services are the same as those for diagnostic tests. Skills of a therapist are defined by the scope of practice for therapists in the state. 485. Regulatory references on Physical Therapists in Private Practice (PTPPs) and Occupational Therapists in Private Practice (OTPPs) are at 42 CFR 410. please refer to Change Request (CR) 6698 at: http://www. Therapist Therapist refers only to qualified physical therapists. Refer to the “Professional Qualification Requirements” in this manual.gov/transmittals/downloads/R327PI. physical therapists and occupational therapists who have Medicare provider numbers. Speech-language pathologists are not suppliers because the act does not provide coverage of any speech-language pathology services furnished by a speech-language pathologist as an independent practitioner. you may notice changes within the request letter. occupational therapists and speech-language pathologists.

o Furnishing a course of treatment where the physician performs an initial direct. There could be multiple visits. procedures. Although PTAs and OTAs work under the supervision of a therapist and their services may be billed by the therapist. treatment sessions/encounters on a treatment day. activities. the course of treatment. this is not considered Rev. including CAHs. occupational therapy and/or speech-language pathology. and management of. It is likely that not all minutes in the visits/treatment sessions are billable (e. o An independent contractor and/or a leased employee of the supervising physician. evaluation and/or reevaluation is provided. When there are two visits/treatment sessions in a day. professional service and performs subsequent services at a frequency that reflects his continuing active participation in. in the morning and afternoon. Treatment Day Treatment day means a single calendar day on which treatment. rest periods). the therapist performing the service may be: o Part time. There may be two treatment sessions in a day. Medicare does not cover physical/occupational therapy services provided “incident to” a therapist or physician/NPP.MEDICARE PART B Therapy Services Therapy Therapy (or outpatient rehabilitation services) includes only outpatient physical therapy.  To be considered an employee for “incident to” purposes of this section.. 01/2012 8 Definition of Terms . Or. occupational therapy and speech-language pathology services paid using the Medicare Physician Fee Schedule or the same services when provided in hospitals that are exempt from the hospital Outpatient Prospective Payment System (OPPS) and paid on a reasonable cost basis. o Full time.g. Visits or Treatment Sessions Visits or treatment sessions begin at the time the patient enters the treatment area (of a building.g. physician group practice or of the legal entity that employs the physician who provides personal supervision. ‘Incident to’ “Incident to” means services that are:  Furnished as an integral part of a physician’s or NPP’s personal professional services and are provided by those trained specifically in physical therapy. services) have been completed for that session and the patient leaves that area to participate in a non-therapy activity.. for example. office or clinic) and continue until all services (e. plans of care indicate treatment amount of twice a day.

unless it is required by state law. chiropractors cannot be considered physicians for the purpose of supervising other services. low-vision specialists or any other profession may not be billed as therapy services. When therapy services are performed “incident to” a physician’s/NPP’s service.” PTA and OTA services are covered under therapy services benefit not the “incident to” benefit. Regardless of the scope of practice for chiropractors as defined by individual states. Note: Therapy services (physical therapy. 01/2012 9 Definition of Terms . Direct Supervision in the Office Direct supervision means the physician must be physically present in the same office suite and immediately available to provide assistance and direction throughout the time the employee is performing services. The qualified personnel must meet all the other requirements except licensure. occupational therapist or speech language pathologist in any other outpatient setting with one exception. Regardless of any state licensing that allows other health professionals to provide therapy services. Qualifications for therapists are found in the Professional Qualification Requirements in this manual. these rules require that the person who furnishes the service to the patient must. This means the services of athletic trainers. occupational therapy and/or speech language pathology) provided “incident to” a physician or NPP requires direct supervision. massage therapists. recreation therapists. the qualified personnel who perform the service do not need to have a license to practice therapy. Coverage extends only to treatment by manipulation of the spine to correct a subluxation demonstrated by X-ray. “incident to” services do not apply in a hospital setting. Rev. In a physician-directed clinic where responsibility is shared for supervision of medical services performed by employees of the clinic. For the purposes of billing the Part B contractor. at least. In effect. Therapy services appropriately billed “incident to” a physician’s/NPP’s service shall be subject to the same requirements as therapy services that would be furnished by a physical therapist. Medicare is authorized to pay only for services provided by those trained specifically in physical therapy. be a graduate of a program of training for one of the therapy services as described above. kinesiotherapists.MEDICARE PART B Therapy Services “incident to. Therefore. occupational therapy or speech-language pathology. Medicare recognizes chiropractors as physicians with respect to specified services. the physician who orders a service is not necessarily the same physician who provides direct medical supervision while the service is performed.

unless state law is more stringent. Supervised Procedure Does not require direct (one-on-one) patient contact. 01/2012 10 Definition of Terms . Medicare payment is denied unless the provider qualifies for a waiver under limitation of liability provisions. Constant Attendance Requires direct (one-on-one) patient contact. Not Covered This term means that a requirement in Medicare’s definition of the benefit category is not met and coverage is denied. although the benefit category requirements are met.MEDICARE PART B Therapy Services Note: General supervision (physical or occupational therapist is available but not necessarily on the premises) is required for PTAs and/or OTAs in all settings but private practice (of the physical or occupational therapist) (CMS-1500 claim form submitters). which requires direct supervision. Not Medically Necessary This term means that. Rev. No Medicare payment is made. the service is not reasonable and necessary for the diagnosis or treatment of the patient’s condition.

osteopathy (including an osteopathic practitioner).  National Certification Corporation of Pediatric Nurse Practitioners and Nurses. 01/2012 11 Professional Qualification Requirements .  Critical Care Certification Corporation. Note: Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.  National Certification Corporation for Obstetric. Payments are made only under assignment. Clinical Nurse Specialist (CNS) A Clinical Nurse Specialist (CNS) is a registered nurse who is currently licensed as a CNS by the state in which he practices.  Oncology Nurses Certification Corporation..  The CNS must have a master’s degree in a defined clinical area of nursing from Rev. The following are recognized national certifying bodies:  American Academy of Nurse Practitioners. He must satisfy the applicable requirements for qualifications of a CNS in the state in which the services are performed.  Be certified as an NP by a recognized national certifying body that has established standards for NPs.  American Nurses Credentialing Center. podiatric medicine or optometry (for low-vision rehabilitation only). a doctor of medicine or doctor of osteopathy (MD/DO)). Gynecologic and Neonatal Nursing Specialties. Nurse Practitioner (NP) A Nurse Practitioner (NP) applying for a Medicare provider number for the first time must meet the following requirements:  Be a registered professional nurse who is authorized by the state in which the services are furnished to practice as an NP in accordance with state law.e.MEDICARE PART B Therapy Services PROFESSIONAL QUALIFICATION REQUIREMENTS Physician Physician with respect to outpatient rehabilitation therapy services means a doctor of medicine.  Possess a master’s degree in nursing. Coverage is available for services performed by an NP working in collaboration with a physician (i. Direct payment can be made to the NP or the employer or contractor of the NP.

01/2012 12 Professional Qualification Requirements .  Have passed the national certification examination administered by the National Commission on Certification of Physician Assistants (NCCPA).e. Physician Assistant (PA) A Physician Assistant (PA) must be legally authorized to furnish services in the state in which he performs them and must meet the following conditions:  Have graduated from a physician assistant educational program that is accredited by the Accreditation Review Commission on Education for the Physician Assistant (its predecessor agencies. The CNS must be certified as a CNS by the American Nurses Credentialing Center. doctor of medicine or doctor of osteopathy (MD/DO))..  Must be employed. Direct payment can be made to the CNS or the employer or contractor of the CNS.MEDICARE PART B Therapy Services  an accredited educational institution. collaboration must be evidenced by NPs/CNSs documenting their scope of practice and indicating the relationships they have with physicians to deal with issues outside their scope of practice. Any service not in the agreement cannot be billed to the Medicare program. There must be a written agreement between the collaborating physician and the NP/CNS for the services provided by the NP/CNS and it must be made available to Medicare upon request. In the absence of state law governing collaboration. Or. Rev. The collaborating physician does not need to be present with the NP/CNS when the services are furnished or to make an independent evaluation of each patient seen by the NP/CNS. Collaboration The term “collaboration” means a process whereby an NP/CNS works with one or more physicians (MD/DO) to deliver health care services with medical direction and appropriate supervision as required by the law of the state in which the services are furnished.  Be licensed by the state to practice as a PA. Payment is made only under assignments. and the Committee on Allied Health Education and Accreditation (CAHEA)). Coverage is available for services performed by a CNS working in collaboration with a physician (i. the Commission on Accreditation of Allied Health Education Programs (CAAHEP).

2007. Or. has graduated from an accredited PT education program and passed a national examination approved by the state in which PT services are provided.  PTs meet the requirements who are currently licensed and were licensed or qualified as a PT on or before December 31. curriculum approval was provided by the American Physical Therapy Association (APTA). from a PT program outside the United States (U. 2010. including temporary licensure. published in the Federal Register on January 15. if they have not met any of the following requirements prior to January 1. The regulation provides that a qualified Physical Therapist (PT) is a person who is licensed. The requirements above apply to all PTs effective January 1.15(e) as it relates to PTs. For internationally educated PTs. See also the correction notice for this rule. 2010.) that is determined to be substantially equivalent to a U.15(e) and also passed an examination for PTs approved by the state in which practicing. The curriculum accreditation is provided by the Commission on Accreditation in Physical Therapy Education (CAPTE) or. Or. qualify to provide PT services to Medicare beneficiaries if they:  Graduated from a CAPTE approved program in PT on or before December 31. 8 CFR 212. 2008. and had two years Rev. See the Federal Register of November 27. 2008. the Committee on Allied Health Education and Accreditation of the American Medical Association.15(e) approved the credentials evaluation provided by the Federation of State Boards of Physical Therapy (FSBPT) and the Foreign Credentialing Commission on Physical Therapy (FCCPT). PTs whose current license was obtained on or prior to December 31. Or.S.MEDICARE PART B Therapy Services Physical Therapist (PT) The new personnel qualifications for physical therapists were discussed in the 2008 Physician Fee Schedule. 2009. regardless of the location of the entity billing the services. For example. graduation from a curriculum approved by either the APTA. as a PT by the state in which he is practicing unless licensure does not apply. in 2007. 2009 (examination is not required).  PTs whose current license was obtained before January 1. if applicable. may meet the requirements in place on that date (i. for those who graduated before CAPTE. 2009.S. “by the state in which practicing” includes any authorization to practice provided by the same state in which the service is provided. The phrase.  Graduated on or before December 31. or both). curricula are approved by a credentials evaluation organization either approved by the APTA or identified in 8 CFR 212. program by a credentials evaluating organization approved by either the APTA or identified in 8 CFR 212. 1977. for the full text..e. 01/2012 13 Professional Qualification Requirements .

Or. published in the Federal Register on January 15. and passed a proficiency examination conducted. a person who. o Admitted to registration by the American Registry of Physical Therapists. 2010. See the Federal Register of November 27. all other personnel qualifications do apply. Physical Therapist Assistant (PTA) Personnel Qualifications The new personnel qualifications for Physical Therapist Assistants (PTA) were discussed in the 2008 Physician Fee Schedule. apply to qualified personnel who provide PT services “incident to” the services of a physician/NPP. 2007. both education and examination requirements that are effective January 1. Or. See also the correction notice for this rule. Or.S. they were: o Admitted to membership by the APTA. 2008. 2010. Or. or sponsored by the U.MEDICARE PART B Therapy Services appropriate experience as a PT. Or o Graduated from a four-year PT curriculum approved by a State Department of Education. On or after January 1. the requirement for PT licensure does not apply. PTs meet the requirements if they are currently licensed and before January 1. For example. 1966. PTs meet requirements if they are currently licensed and they were trained outside the U. they had 15 years of fulltime experience in PT under the order and direction of attending and referring doctors of medicine or osteopathy. if that country had an organization that was a member of the World Confederation for Physical Therapy. 01/2012 14 Professional Qualification Requirements . and after 1928 graduated from a PT curriculum approved in the country in which the curriculum was located. approved. 2008. could provide Medicare outpatient PT therapy services “incident to” the services of a physician/NPP if the physician assumes responsibility for the services according to the “incident to” policies. Rev. before January 1. and that PT qualified as a member of the organization. 2009.S. Public Health Service. graduated from a PT curriculum accredited by CAPTE.   For outpatient PT services that are provided “incident to” the services of physicians/ Non-Physician Practitioners (NPPs). o Licensed or registered and prior to January 1. on or before December 31. although licensure does not apply. but who has not passed the national examination or obtained a license. The qualified personnel providing PT services “incident to” the services of a physician/NPP must be trained in an accredited PT curriculum. for the full text. 1970.

that is. These services are billed by the supervising physical therapist. The phrase. 01/2012 15 Professional Qualification Requirements . from a two-year college-level program approved by the APTA or CAPTE. they were licensed or qualified as a PTA and passed a proficiency examination conducted. o Effective January 1. is registered or certified. on or before December 31. These requirements above apply to all PTAs effective January 1. 2009. Those PTAs also qualify who. or where licensure does not apply. Approval for the curriculum is provided by CAPTE or. if applicable. 2010. 2010. registered or certified as a PTA and met one of the two following requirements:  Is licensed or otherwise regulated in the state in which practicing. 2008. for example the one furnished by the Federation of State Boards of Physical Therapy. Or. from a two-year college level program approved by the APTA. 2009. those PTAs must have both graduated from a CAPTE approved curriculum and passed a national examination for PTAs. “by the state in which practicing” includes any authorization to practice provided by the same state in which the service is provided. A national examination for PTAs is. 1977.  In states that have no licensure or other regulations. regardless of the location or the entity billing for the services. if they have not met any of the following requirements prior to January 1. Public Health Service. including temporary licensure. if applicable and meet requirements in effect before January 1. o On or before December 31. if internationally or military trained PTAs apply.MEDICARE PART B Therapy Services The regulation provides that a qualified PTA is a person who is licensed as a PTA unless licensure does not apply. And.S. and graduated from an approved curriculum for PTAs. as a PTA by the state in which practicing. Services The services of PTAs when providing covered therapy benefits are included as part of the covered service. registered or certified as a PTA. are licensed. 2008. PTAs have: o Graduated on or before December 31. o PTAs may also qualify if they are licensed. They act under the direction and supervision of the treating physical therapist and in accordance with state laws. approved. Or. PTAs may not provide evaluation services. and passed a national examination for PTAs. approval will be through a credentialing body for the curriculum for PTAs identified by either the American Physical Therapy Association or identified in 8 CFR 212. or sponsored by the U. make clinical judgments or decisions or take responsibility for the service. they have graduated before January 1. 2010. Rev.15(e).

2007. if they have not met any of the following requirements prior to January 1. The OTs may also qualify if on or before December 31. published in the Federal Register on January 15. (NBCOT). The level and frequency of supervision differs by setting (and by state or local law). 2009:  They are licensed or otherwise regulated as an OT in the state in which practicing (regardless of the qualifications they met to obtain that licensure or regulation) Or. and graduated from an accredited education program for OTs. 2008.S. “by the state in which practicing” includes any authorization to practice provided by the same state in which the service is provided. qualify to provide OT services for Medicare beneficiaries if:  On or before January 1. Occupational Therapist (OT) The new personnel qualifications for Occupational Therapists (OT) were discussed in the 2008 Physician Fee Schedule.4 prior to January 1. in which case state or local requirements must be followed. OTs have graduated from an OT education program accredited by ACOTE and are eligible to take. therefore. as an OT by the state in which practicing. 2008. if licensure applies. The regulation provides that a qualified OT is an individual who is licensed. they are not allowed to receive a Medicare provider number. The education program for U. including temporary licensure. 2010. those OTs who met the Medicare requirements for OTs that were in 42CFR484. 2010. for the full text. which requires direct supervision unless state practice requirements are more stringent. Their services can only be billed by the supervising physical therapist. and is eligible to take or has passed the examination for OTs administered by the National Board for Certification in Occupational Therapy. See the Federal Register of November 27. or otherwise regulated. The phrase. The services of a PTA shall not be billed as services “incident to” a physician’s/NPP’s service because they do not meet the qualifications of a therapist. if applicable. Note: Medicare does not recognize PTAs as providers. or have successfully completed the NBCOT examination for OTs. General supervision is required for PTAs in all settings except private practice (CMS-1500 claim form submitters). regardless of the location of the entity billing the services. they graduated an OT program approved jointly by Rev. The requirements above apply to all OTs effective January 1. Also. Inc.MEDICARE PART B Therapy Services A physical therapist must supervise PTAs.  When licensure or other regulation does not apply. 2008. 01/2012 16 Professional Qualification Requirements . See also the correction notice for this rule. trained OTs is accredited by the Accreditation Council for Occupational Therapy Education (ACOTE).

2008. the requirement for OT licensure does not apply.S. or otherwise regulated. Or. apply to qualified personnel who provide OT services “incident to” the services of a physician/NPP. approved.  Also. 2007. For outpatient OT services that are provided “incident to” the services of physicians/ NPPs. The qualified personnel providing OT services “incident to” the services of a physician/NPP must be trained in an accredited OT curriculum. are licensed or otherwise regulated. or a credentialing body approved by AOTA. For example. and had achieved a satisfactory grade on a proficiency examination conducted. OT education program by ACOTE. had two years of appropriate experience as an occupational therapist. for the full text. 01/2012 17 Professional Qualification Requirements .  Effective January 1. See also the correction notice for this rule. the World Federation of Occupational Therapists.  Passed the NBCOT examination for OT. unless licensure does not apply. as an OTA by the state in which Rev. all other personnel qualifications do apply. 2010. graduated from an OT curriculum accredited by ACOTE and is eligible to take or has successfully completed the entry-level certification examination for OTs developed and administered by NBCOT. a person who.MEDICARE PART B Therapy Services the American Medical Association and the American Occupational Therapy Association (AOTA). Those educated outside the U. on or before December 31. may meet the same qualifications for domestic trained OTs. 2009. they qualify who on or before December 31. On or after January 1. 2010. For example. they qualify if they were licensed or otherwise regulated by the state in which practicing on or before December 31. both education and examination requirements that are effective January 1. although licensure does not apply. 2010. Public Health Service. if applicable. The regulation provides that an OTA is a person who is licensed. Or they are qualified if they:  Graduated from an OT education program accredited as substantially equivalent to a U. 2009.S. See the Federal Register of November 27. could provide Medicare outpatient OT services “incident to” the services of a physician/NPP if the physician assumes responsibility for the services according to the “incident to” policies. published in the Federal Register on January 15. They are eligible for the National Registration Examination of AOTA or the National Board for Certification in OT.S. Occupational Therapist Assistant (OTA) The new personnel qualifications for Occupational Therapy Assistants (OTAs) were discussed in the 2008 Physician Fee Schedule. if applicable as an OT by the state in which practicing. 1977. or sponsored by the U.

An OT must supervise OTAs. and on or before December 31. by ACOTE. and graduated from an OTA education program accredited by ACOTE and is eligible to take or has successfully completed the NBCOT examination for OTAs. If the requirements above are not met. on or after January 1. 2008. if applicable. where licensure or other state regulation does not apply.  Completed the requirements to practice as an OTA applicable in the state in which practicing. they must have graduated from an OTA program accredited as substantially equivalent to OTA entry-level education in the U. 1977. on or before December 31. or meets any qualifications defined by the state in which practicing. 2010. continue to qualify to provide OT directed and supervised OTA services to Medicare beneficiaries. if educated outside the U. OTAs who qualified under the policies in effect prior to January 1. Therefore. “by the state in which practicing” includes any authorization to practice provided by the same state in which the service is provided. including temporary licensure. OTAs qualify who after December 31. or the World Federation of Occupational Therapists or a credentialing body approved by AOTA. may meet the same requirements as domestically-trained OTAs. General supervision is required for OTAs in all settings except private practice (which requires direct supervision) unless state practice Rev.S.S. 2009:  Completed certification requirements to practice as an OTA established by a credentialing organization approved by AOTA. Those OTAs who were educated outside the U. OTAs may not provide evaluation services. on or before December 31. Or. 2008. Or. OTAs may qualify if they have. 01/2012 18 Professional Qualification Requirements . its successor organization. They act under the direction and supervision of the treating OT and in accordance with state laws. These services are billed by the supervising OT. The level and frequency of supervision differs by setting (and by state or local law). Services The services of OTAs used when providing covered therapy benefits are included as part of the covered service. an OTA may qualify if. they must have passed an exam for OTAs administered by NBCOT. regardless of the location of the entity billing the services. they have also completed an education program accredited by ACOTE and passed the NBCOT examination for OTAs. In addition. The phrase. Or. 2009. by the state in which practicing.  After January 1. 2007:  Completed certification requirements to practice as an OTA established by a credentialing organization approved by AOTA.S.MEDICARE PART B Therapy Services practicing. make clinical judgments or decisions or take responsibility for the service. the OTA is licensed or otherwise regulated as an OTA.

Rev. they are not allowed to receive a Medicare provider number. Note: Medicare does not recognize OTAs as providers. Therefore. 2009. The services of an OTA shall not be billed as services “incident to” a physician’s/NPP’s service because they do not meet the qualifications of a therapist. 01/2012 19 Professional Qualification Requirements . and after: Section 143 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to enroll speech-language pathologists (SLPs) as suppliers of Medicare services and for SLPs to begin billing Medicare for outpatient speechlanguage pathology services furnished in private practice beginning July 1. For speech-language pathology services rendered prior to July 1. A qualified SLP for program coverage purposes meets one of the following requirements:  The education and experience requirements for a Certificate of Clinical Competence in (speech-language pathology or audiology) granted by the American Speech-Language Hearing Association. For outpatient speech-language pathology services that are provided “incident to” the services of physicians/NPPs. 2009. Their services can only be billed by the supervising OT. qualified personnel providing speech-language pathology services “incident to” the services of a physician/NPP must meet the above qualifications. therefore. therefore.MEDICARE PART B Therapy Services requirements are more stringent. These services were non-covered. 2009. Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services. the requirement for speech-language pathology licensure does not apply. physician or non-physician practitioner billed them. 2009: Medicare did not recognize SLPs as Part B providers prior to July 1. Speech-Language Pathologist (SLP) For speech-language pathology services rendered July 1. all other personnel qualifications do apply. state or local requirements must be followed. they were not allowed to receive a Medicare provider number and bill Medicare Part B.  Meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification. Previously. in which case. the Medicare program could only pay speechlanguage pathology services if an institution.

Rev. 01/2012 20 Professional Qualification Requirements . Services provided by aides.MEDICARE PART B Therapy Services Speech-Language Pathologist Assistants (SLPAs) Services of Speech-Language Pathologist Assistants (SLPAs) are not recognized for Medicare coverage. Services provided by SLPAs. those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services. even if they are licensed to provide services in their states. will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services. even if under the supervision of a therapist. Although an aide may help the therapist by providing unskilled services. are not therapy services and are not covered by Medicare.

the practice/office or provider shall rent or lease the pool. each individual must be enrolled as a private practitioner and employed in one of the following practice types: an unincorporated solo practice. unincorporated group practice. Services Furnished by a TPP To qualify to bill Medicare directly as a therapist. if applicable) is legally authorized to furnish services. Physician/NPP group practices may employ TPP if state and local laws permit this employee relationship. “TPP” refers to therapists in private practice (qualified PTs. Example: When therapy services may be furnished appropriately in a community pool by a clinician in a therapist’s private practice. unincorporated partnership. “Therapist” refers only to a qualified PT. OT or SLP. refer to the Professional Qualification Requirements in this manual. that space shall be owned. Services should be furnished in the therapist’s or group’s office or in the patient’s home. The written agreement to rent or lease the pool shall be available for review on request. OTs and SLPs). outpatient hospital or outpatient Skilled Nursing Facility (SNF). For further details on issues concerning enrollment. during the hours that the therapist engages in the practice at that location. physician office. if allowed by state and local law. a physician/NPP group practice is defined as one or more physicians/NPPs enrolled with Medicare who may bill as one entity. leased or rented by the practice and used for the exclusive purpose of operating the practice. For purposes of this provision. or a specific portion of the pool.cms. If services are furnished in a private practice office space. 01/2012 21 Medicare Enrollment of Therapists in Private Practice . Private practice does not include individuals when they are working as employees of an institutional provider. and Speech-Language Pathologist (SLP). The use of that part of the pool during specified times shall be restricted to the patients of that practice or provider. in the state(s) where the therapist (and practice. see the Provider Enrollment Web site at: http://www.MEDICARE PART B Therapy Services MEDICARE ENROLLMENT OF THERAPISTS IN PRIVATE PRACTICE (TPPs) For enrollment requirements for a Physical Therapist (PT). Occupational Therapist (OT).gov/MedicareProviderSupEnroll/ Private practice also includes therapists who are practicing therapy as employees of another supplier. physician/Non-Physician Practitioner (NPP) group or groups that are not professional corporations. Office Setting The office is defined as the location(s) where the practice is operated. When part Rev. of a professional corporation or of another incorporated therapy practice.

are subject to the requirements outlined in the respective State Operations Manual regarding rented or leased community pools. leased or rented may be satisfied by the group that employs the therapist. Other providers. the agreement shall describe the part of the pool that is used exclusively by the patients of that practice/office or provider and the times that exclusive use applies. The services of support Rev. In other outpatient settings. the requirement that therapy space be owned. The therapist does not have to be in full-time private practice but must be engaged in private practice on a regular basis. with the therapist identified on the claim as the supplier of services. If a therapist is not enrolled.MEDICARE PART B Therapy Services of the pool is rented or leased. Each therapist employed by a group should enroll as a TPP. services of the therapist who has a Medicare NPI may also be billed by the physician/NPP as services “incident to” the physician’s/NPP’s service. 01/2012 22 Medicare Enrollment of Therapists in Private Practice . Direct supervision requires that the supervising private practice therapist be present in the office suite at the time the service is performed. the services are ordinarily billed as services of the therapist. or a therapist is employed by another supplier and furnishes services in facilities provided at the expense of that supplier.. In that case. the services of that therapist must be directly supervised by an enrolled therapist. the therapist is recognized as a private practitioner. physician/NPP groups or groups that are not professional organizations. If a therapist who has a Medicare NPI is employed in a physician’s/NPP’s office. When therapists with a Medicare NPI provide services in the physician’s/NPP’s office in which they are employed. the physician/NPP is the supplier of service. and for that purpose has access to the necessary equipment to provide an adequate program of therapy. However. Each TPP should be enrolled as a Medicare provider. These direct supervision requirements apply only in the private practice setting and only for therapists and their assistants. the NPI of the supervising physician/NPP is reported on the claim with the service and all the rules for both therapy services and “incident to” services must be followed. supervision rules differ.e. including providers of outpatient physical therapy and speech-language pathology and CORFs. The therapy services must be provided either by or under the direct supervision of the TPP. i. then the direct supervision requirement for enrolled staff applies. If therapists who have their own National Provider Identifier (NPI) are employed by therapist groups. Private Practice Defined The contractor considers a therapist to be in private practice if the therapist maintains office space at his own expense and furnishes services only in that space or the patient’s home. and bill using their NPI for each therapy service.

Rev.  04/Homeless Shelter. For this purpose. when these services are not furnished on an assignment-related basis. If physicians.  33/Custodial Care Facility. The supporting personnel. In contrast. However. the limiting charge applies. The services of support personnel must be included in the therapist’s bill. other than a facility that is a private residence. owned or leased by the physician group.  14/Group Home. rehabilitation agencies and CORFs do not have the option. just as required for physicians in a group practice who are reassigning their benefits to the physician group practice. 01/2012 23 Medicare Enrollment of Therapists in Private Practice . Medicare will only pay 95 percent of the fee schedule amount. including other therapists. Note: Services furnished by a therapist in the therapist’s office under arrangements with hospitals in rural communities and public health agencies (or services provided in the beneficiary’s home under arrangements with a provider of outpatient physical or occupational therapy services) are not covered under this provision. but not a hospital. Therapists in a Physician Group Therapists in a physician group can be either salaried (W-2) employees or contract (1099) employees. must be salaried (W-2) or contract (1099) employees of the TPP or other qualified employer.MEDICARE PART B Therapy Services personnel must be included in the therapist’s bill. Medicare pays 80 percent and the patient is responsible for 20 percent. NPPs or TPPs accept assignment (are participating). Community Access Hospital (CAH) or SNF. If they do not accept assignment. assignment is mandatory. Assignment When physicians. they have the option of accepting assignment (participating) or not accepting assignment (non-participating). NPPs or TPPs obtain provider numbers. “home” includes an institution that is used as a home. providers such as outpatient hospitals. only if residential.  12/Home. Places of Service (POS) include:  03/School. SNFs. Coverage of outpatient physical therapy and occupational therapy under Part B includes the services of a qualified TPP when furnished in the therapist’s office or the beneficiary’s home. For these providers. The TPP contract employee must follow current reassignment rules that indicate these services must be provided on premises that are rented. they must accept the Medicare Physician Fee Schedule amount as payment.

MEDICARE PART B Therapy Services Supervision Therapists in private practice employed by physician groups or non-professional corporations who enroll in Medicare as a TPP need not be supervised. Supervision The therapist must provide direct supervision to PTAs and OTAs. will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services.trailblazerhealth. Services provided by aides. their services are covered under the benefit for therapy services and not by the benefit for services “incident to” a physician/NPP. Direct supervision requires that the therapist be present in the office suite and immediately available to furnish assistance and direction during the performance of the service. Services provided by SLPAs. even if they are licensed to provide services in their states. The services furnished by PTAs and OTAs are not “incident to” the therapist’s service.com/Provider Enrollment ‘Incident to’ Services for Physical Therapist Assistants (PTAs) and Occupational Therapist Assistants (OTAs) There is no coverage for services provided “incident to” the services of a therapist. Although PTAs and OTAs work under the supervision of a therapist and their services may be billed by the therapist. Please refer to the Provider Enrollment page on the TrailBlazer Health Enterprises Web site for more information: http://www. are not therapy services and are not covered by Medicare. Although an aide may help the therapist by providing unskilled services. even if under the supervision of a therapist. Rev. those services are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services. Services of Speech-Language Pathology Support Personnel Services of Speech-Language Pathology Assistants (SLPAs) are not recognized for Medicare coverage. 01/2012 24 Medicare Enrollment of Therapists in Private Practice .

01/2012 25 Therapy Performed by Licensed Therapists in Private Practice . Supervision The therapist must provide direct supervision to PTAs and OTAs. amount. The patient is responsible for any unmet deductible and the 20 percent coinsurance. Note: If the requirements are not met. The plan of treatment must indicate the type. Occupational Therapists (OTs) and Speech-Language Pathologists (SLPs) (for speech-language pathology services rendered July 1.MEDICARE PART B Therapy Services THERAPY PERFORMED BY LICENSED THERAPISTS IN PRIVATE PRACTICE Coverage Criteria Medicare provides coverage for Licensed Physical Therapists (LPTs).trailblazerhealth. Rev. The following conditions must be met:  The patient must be under the care of a physician/Non-Physician Practitioner (NPP). frequency and duration of the physical therapy services and the diagnosis and long-term goals. there is no coverage for services provided “incident to” the services of a therapist. Refer to the “Documentation Requirements” section in this manual for more information on the plan of treatment. the therapy services are not covered (reasonable and necessary). Although Physical Therapist Assistants (PTAs) and Occupational Therapist Assistants (OTAs) work under the supervision of a therapist and their services may be billed by the therapist.  The services must be furnished under a plan of treatment established and reviewed by the attending physician. Reimbursement Reimbursement for outpatient physical therapy by a TPP is based on 80 percent of the Medicare Physician Fee Schedule or the actual charge. Direct supervision requires that the therapist be present in the office suite and immediately available to furnish assistance and direction during the performance of the service. and after) in private practice for therapy furnished in the therapist’s office or the patient’s home. 2009. their services are covered under the benefit for therapy services and not by the benefit for services “incident to” a physician/NPP.com/Payment/Fee Schedules/ As a reminder. The fee schedule is published on the TrailBlazer Web site at: http://www. The services furnished by PTAs and OTAs are not “incident to” the therapist’s service.

providing motor and tactile activities to increase sensory input and improve response for a stroke patient with functional loss resulting in a distorted body image. for specific conditions or services at http://www. to improve the individual’s ability to perform those tasks required for independent functioning.asp.) Occupational therapy is medically prescribed treatment concerned with improving or restoring functions that have been impaired by illness or injury or. not separately billable. where function has been permanently lost or reduced by illness or injury.cms..g. looms. Occupational Therapy Occupational therapy services are those services provided within the scope of practice of OTs and necessary for the diagnosis and treatment of impairments. electrodes.  The planning.g.g. implementing and supervising of individualized therapeutic activity programs as part of an overall “active treatment” program for a patient with a diagnosed psychiatric illness. the use of sewing activities that require following a pattern to reduce confusion and restore reality orientation in a schizophrenic patient. functional disabilities or changes in physical function and health status.. hand putty. because they do not meet the qualifications of a therapist. Such therapy may involve:  The evaluation and re-evaluation as required of a patient’s level of function by administering diagnostic and prognostic tests.  The teaching of compensatory technique to improve the level of independence in the activities of daily living.  The planning and implementing of therapeutic tasks and activities to restore sensory-integrative function. even if under the supervision of a therapist. 01/2012 26 Therapy Performed by Licensed Therapists in Private Practice .. therefore. Aides Services provided by aides. e. elbow and wrist range of motion lost as a result of burns..g. for example: Rev. theraband.  The selection and teaching of task-oriented therapeutic activities designed to restore physical function. use of woodworking activities on an inclined table to restore shoulder. (See IOM Pub. e. ceramic tiles or leather) used in furnishing covered therapy care is included in the payment for the HCPCS codes billed by the physical therapist and are. Although an aide may help the therapist by providing unskilled services.MEDICARE PART B Therapy Services Note: The services of a PTA/OTA shall not be billed as services “incident to” a physician’s/NPP’s service. those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services. Supplies The cost of supplies (e. e. are not therapy services in the outpatient setting and are not covered by Medicare. 100-03.gov/Manuals/IOM/list. the Medicare National Coverage Determinations Manual.

g. an assessment of sitting and Rev. are services OTs provide for both vocational and non-vocational purposes. When services provided by an OT are related solely to specific employment opportunities. training and experience required to evaluate. o Teaching a patient with a hip fracture or hip replacement techniques of standing tolerance and balance to enable the patient to perform such functional activities as dressing and homemaking tasks. Application of Medicare Guidelines to Occupational Therapy Services Occupational therapy may be required for a patient with a specific diagnosed psychiatric illness. they are covered assuming the coverage criteria are met. However. especially in activities of daily living. contractors and intermediaries exercise care in applying this exclusion because the assessment of level of function and the teaching of compensatory techniques to improve the level of function.. which is interwoven with other functions performed by such personnel for the patient. Occupational therapy may include vocational and prevocational assessment and training. subject to the limitations for qualified OTs specified. the meeting of such needs does not usually require an individualized therapeutic program. when an individual’s motivational needs are not related to a specific diagnosed psychiatric illness.MEDICARE PART B Therapy Services o Teaching a patient who has lost the use of an arm how to pare potatoes and chop vegetables with one hand. and where appropriate. o Teaching an upper extremity amputee how to functionally use a prosthesis. recommend to the physician/NPP a plan of treatment. e. Patient motivation is an appropriate and inherent function of all health disciplines. Services furnished under such a program are not covered. work skills or work settings. determine whether an occupational therapy program could reasonably be expected to improve. making a hand splint for a patient with rheumatoid arthritis to maintain the hand in a functional position or constructing a device that would enable an individual to hold a utensil and feed independently. restore or compensate for lost function. For example. re-evaluate a patient’s level of function. Vocational and prevocational assessment and training. fabricating and fitting of orthotics and self-help devices. since the special skills of an OT are not required. 01/2012 27 Therapy Performed by Licensed Therapists in Private Practice . If such services are required. an occupational therapy program for individuals who do not have a specific diagnosed psychiatric illness is not to be considered reasonable and necessary for the treatment of an illness or injury. Accordingly. o Teaching a stroke patient new techniques to enable the patient to perform feeding. dressing and other activities as independently as possible. and. However. The designing. as necessary. they are not reasonable or necessary for the diagnosis or treatment of an illness or injury and are not covered. Such needs can be met through general activity programs or the efforts of other professional personnel involved in the care of the patient.   Only a qualified OT has the knowledge.

01/2012 28 Therapy Performed by Licensed Therapists in Private Practice . a Western Aphasia Battery for a patient undergoing a rehabilitative speech-language pathology program.. Although hearing screening by the SLP may be part of an evaluation. e. The SLP employs a variety of formal and informal speech. Impairments of the Auditory System Aural rehabilitation. language and dysphagia assessment tests to ascertain the type. This list is not allinclusive:  Cerebrovascular disease such as cerebral vascular accidents presenting with dysphagia. inadequate respiratory volume/control or voice disorder. but could also be a vocational test for a sales clerk. apraxia and dysarthria. auditory rehabilitation.  Laryngeal carcinoma requiring laryngectomy resulting in aphonia. aphasia/dysphasia.g. Training an amputee in the use of a prosthesis for telephoning is necessary for everyday activities as well as for employment purposes. Major changes in lifestyle may be mandatory for an individual with a substantial disability.  Neurological disease such as Parkinsonism or multiple sclerosis with dysarthria. The techniques of adjustment cannot be considered exclusively vocational or non-vocational. which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia). are considered a part of the treatment session and shall not be covered as a separate evaluation for billing purposes. auditory processing. which may necessitate active rehabilitative therapy. dysphagia. Re-evaluation of patients for whom speech. it is not billable as a separate service. Practice of Speech-Language Pathology Speech-language pathology services are those services provided within the scope of practice of Speech-Language Pathologists (SLPs) and necessary for the diagnosis and treatment of speech and language disorders. Therapeutic Services The following are examples of common medical disorders and resulting communication deficits. lip reading and speech reading are among the terms used to describe covered services related to perception and comprehension of sound through the auditory system. causal factor(s) and severity of the speech and language or swallowing disorders. language and swallowing were previously contraindicated is covered only if the patient exhibits a change in medical condition. However. Application of Medicare Guidelines to Speech-Language Pathology Services Evaluation Services Speech-language pathology evaluation services are covered if they are reasonable and necessary and not excluded as routine screening by Section 1862(a)(7) of the Social Security Act. monthly re-evaluations.MEDICARE PART B Therapy Services standing tolerance might be non-vocational for a mother of young children or a retired individual living alone. regardless of the presence of a communication disability. Rev.

Evaluation and treatment for disorders of the auditory system may be covered and medically necessary.MEDICARE PART B Therapy Services For example: Auditory processing evaluation and treatment may be covered and medically necessary. The equipment used in the examination may be fixed. the beneficiary’s performance in both clinical and natural environment should be considered. Audiologists and SLPs both evaluate beneficiaries for disorders of the auditory system using different skills and techniques. but only SLPs may provide treatment. when it has been determined by an SLP in collaboration with an audiologist that the hearing-impaired beneficiary’s current amplification options (hearing aid. Examples include but are not limited to services for certain neurological impairments or the absence of natural auditory stimulation that results in impaired ability to process sound. Dysphagia Dysphagia.g. For these reasons. multimodal (e. communication strategies. pulmonary problems. education and counseling. failure to thrive. listening skills. pneumonia and death. and the impact of the hearing loss on the patient/client and family. dementias and encephalopathies. Certain auditory processing disorders require diagnostic audiological tests in addition to speech-language pathology evaluation and treatment. visual. speech reading. aspiration or inadequate nutrition and hydration with resultant weight loss. signed or written modalities. speech and voice production. neuromuscular degenerative diseases. other amplification device or cochlear implant) will not sufficiently meet the patient’s functional communication needs. for example. choking. signed or written modalities. can cause food to enter the airway. 01/2012 29 Therapy Performed by Licensed Therapists in Private Practice . auditory-visual and tactile) training. mobile or portable. auditory training. Assessment of the need for rehabilitation of the auditory system (but not the vestibular system) may be done by an SLP. In determining the necessity for treatment. speech reading. it is important that only qualified professionals with specific training and experience in this disorder provide evaluation and treatment. resulting in coughing. Professional guidelines recommend that the service be provided in a team setting with a physician/NPP who provides Rev. cerebrovascular accident. Examples include but are not limited to evaluation of comprehension and production of language in oral. Examples of rehabilitation include but are not limited to treatment that focuses on comprehension and production of language in oral. It is most often due to complex neurological and/or structural impairments including head and neck trauma. communications strategies. or difficulty in swallowing. head and neck cancer.. speech and voice production. The SLP performs clinical and instrumental assessments and analyzes and integrates the diagnostic information to determine candidacy for intervention as well as appropriate compensations and rehabilitative therapy techniques.

recommending methods of oral intake and risk precautions. Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same qualified professional who established the plan and that plan is established and signed by close of business on the next day by the same qualified professional. pharyngeal.  Physical therapy services that do not require the professional skills of a qualified PT to perform or supervise are not medically necessary. Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function. Physical Medicine and Rehabilitation Denial Reasons For claims submitted by a therapist’s practice:  An order.  Services not furnished in the therapist’s office or in the patient’s home are not covered. for therapy service.  Services not performed by or under the direct personal supervision of the therapist are not covered.  Claims submitted by anyone other than a Medicare certified therapist are not covered. Rev. sometimes called a referral. experience and demonstrated competencies.  Services performed by persons who are not employees of the therapist are not covered.  Services performed under a written treatment plan that has not been certified by a physician or NPP within 30 days from the initial treatment. and developing a treatment plan employing appropriate compensations and therapy techniques. 01/2012 30 Therapy Performed by Licensed Therapists in Private Practice . laryngeal and respiratory function examination as it relates to the functional assessment of swallowing. Swallowing assessment and rehabilitation are highly specialized services. conducting an oral. The professional rendering care must have education.  Services not related to a written treatment plan established by the therapist or by the physician before treatment began are not covered. provides evidence of both the need for care and that the patient is under the care of a physician.MEDICARE PART B Therapy Services supervision of the radiological examination and interpretation of medical conditions revealed in it.  Occupational therapy services that do not require the professional skills of a qualified OT to perform or supervise are not medically necessary. if it is documented in the medical record.

Documentation must be made available to Medicare upon request. A physician is defined as a doctor of medicine. that an individual be under the care of a physician or NPP and that a plan of care be established. Claim Form Requirements Claims for therapy services personally performed by physicians and qualified NPPs. physician certifications and recertifications by doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law. Physical Medicine and Rehabilitation (PM&R) Medicare’s reimbursement of Physical Medicine and Rehabilitation (PM&R) in the home and office setting requires. Coverage extends only to treatment by manipulation of the spine to correct a subluxation demonstrated by X-ray. Claims for therapy services reported for Medicare payment by physicians and qualified NPPs. Rev. Medicare would expect that the person(s) providing the physical therapy services be highly knowledgeable. osteopathy or podiatric medicine legally authorized to practice by the state in which he performs the services. but not personally performed by the physician or NPP. These services must be provided by the physician or non-physician or under the direct supervision of the physician or nonphysician.MEDICARE PART B Therapy Services PHYSICAL THERAPY PERFORMED BY A PHYSICIAN/NONPHYSICIAN PRACTITIONER (NPP) Coverage Requirements Medicare covers physical therapy when performed in the office setting of a physician or Non-Physician Practitioner (NPP) if the service is medically reasonable and necessary for the treatment of an illness or injury. among other criteria. and reported for Medicare payment on or after July 1. An NPP is defined as a Nurse Practitioner (NP). and reported for Medicare payment on or after July 1. The physician must document in the patient’s medical records the medical necessity of any physical therapy treatment provided to the patient in the office setting. Therefore. 2010. In addition. must contain the following information:  Name and therapy degree of performing therapy professional. 2010. chiropractors cannot be considered physicians for the purpose of supervising other services. Note: Regardless of the scope of practice for chiropractors as defined by individual states. Medicare recognizes chiropractors as physicians with respect to specified services. 01/2012 31 Physical Therapy Performed by a Physician/NPP . skilled and trained in the field of physical therapy. must contain the name and professional degree of the performing professional. Clinical Nurse Specialist (CNS) or Physician Assistant (PA).

com/Publications/PDF Form/Fax-MailEMCDocForms. refer to: http://www. Non-Physician Practitioners (NPPs). Name and professional degree of supervising physician/NPP.pdf For complete claim form instructions. Reimbursement Reimbursement for outpatient physical therapy by a physician is based on the 80 percent of the Medicare Physician Fee Schedule or the actual charge. 01/2012 32 Physical Therapy Performed by a Physician/NPP . Medicare then pays 80 percent of this amount or 80 percent of the actual charge. EMC Claim Please include the information above in the comment field of the electronic claim or the information may be faxed. Fee Schedule The fee schedule is published on the TrailBlazer Web site at: http://www.trailblazerhealth.com/Payment/Fee Schedules/ ‘Incident to’ Related to Physical/Occupational Therapy by Physicians and Non-Physician Practitioners (NPPs) Therapy services have their own benefit under Section 1861 of the Social Security Act and shall be covered when provided according to the standards and conditions of the benefit described in Medicare manuals. refer to: http://www.pdf Note: Claims will be denied if this information is not submitted with the claim. that would apply to a therapist. other than licensing.com/Publications/Training Manual/claim form instructions. Physician Assistants (Pas). The statute 1862(a)(20) requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions. The patient is responsible for any unmet deductible and the 20 percent coinsurance.trailblazerhealth.trailblazerhealth. CMS-1500 Claim Form Please include the information above on an attachment and submit with the claim. For fax information. Rev. Nurse Practitioners (NPs) and Clinical Nurse Specialists (CNSs) Reimbursement for eligible services would be 85 percent of the physician fee schedule. Date of graduation.MEDICARE PART B Therapy Services    Name of academic institution having conferred therapy degree.

or the services of the OTA.MEDICARE PART B Therapy Services Note: Refer to the Professional Qualification Requirements section in this manual. 01/2012 33 Physical Therapy Performed by a Physician/NPP . low-vision specialists or any other profession may not be billed as therapy services. if a PT and PTA (or an OT and OTA) are both employed in a physician’s office. recreation therapists. However. When therapy services are performed “incident to” a physician’s/NPP’s service. when directly supervised by the PT. Occupational Therapist (OT) or SpeechLanguage Pathologist (SLP) in any other outpatient setting with one exception. be a graduate of a program of training for one of the therapy services as described above. massage therapists. occupational therapy or speech-language pathology. (Refer to the Medicare Enrollment of Physical Therapists and Occupational Therapists in Private Practice section in this manual for private practice rules on billing services performed in a physician’s office. The qualified personnel must meet all the other requirements except licensure. the qualified personnel who perform the service do not need to have a license to practice therapy unless it is required by state law. may be billed by the physician group as physical therapy or occupational therapy services using the National Provider Identifier (NPI) of the enrolled PT (or OT). Refer to Professional Qualification Requirements in this manual for qualifications for therapists. Physical Medicine and Rehabilitation Denial Reasons For physicians or NPPs:  Services performed by non-employees or employees that do not meet the qualification standards for providing therapy and those not under a physician’s or NPP’s direct supervision. at least. Medicare is authorized to pay only for services provided by those trained specifically in physical therapy. Rev.  Services not related to a written treatment plan are not medically necessary.  Services that do not require the professional skills of a physician to perform or supervise them are not medically necessary.) If the PT or OT is not enrolled. In effect. are not covered. kinesiotherapists. The services of Physical Therapist Assistants (PTAs) and Occupational Therapist Assistants (OTAs) also may not be billed “incident to” a physician’s/NPP’s service. As a reminder. Medicare shall not pay for the services of a PTA or OTA billed “incident to” the physician’s service because they do not meet the qualification standards for providing therapy. these rules require that the person who furnishes the service to the patient must. This means the services of athletic trainers. the services of the PTA. therapy services appropriately billed “incident to” a physician’s/NPP’s service shall be subject to the same requirements as therapy services that would be furnished by a Physical Therapist (PT). Regardless of any state licensing that allows other health professionals to provide therapy services. when directly supervised by the OT.

o Activity Measure – Post-Acute Care (AM-PAC). The services must be furnished according to a written treatment plan determined by the physician/NPP or by the therapist who will provide the treatment after an appropriate assessment of the condition (illness or injury). Results of one of the following four measurements are recommended: o National Outcomes Measurement System (NOMS) by the American SpeechLanguage Hearing Association. functional assessment. Inc. The medical record must identify the physician/Non-Physician Practitioner (NPP) responsible for the general medical care. maintained in the patient’s medical record and must be made available to Medicare upon request. o Patient Inquiry by Focus on Therapeutic Outcomes. re-evaluation and 34 Conditions of Coverage       Rev. but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan. especially those factors that influence the clinician’s decision to provide more services that are typical for the individual’s condition. 01/2012 . Evaluation. provides evidence of both the need for care and that the patient is under the care of a physician. If the results of one of the four instruments listed above are not recorded. o OPTIMAL by Cedaron through the American Physical Therapy Association. and expected frequency and number of treatments.MEDICARE PART B Therapy Services CONDITIONS OF COVERAGE Documentation  Documentation supporting the medical necessity should be legible. examination. Documentation should establish through objective measurements that the patient is making progress toward goals. (FOTO). the body areas to be treated. diagnosis. the date therapy was initiated. Payment is dependent on the certification of the plan of care rather than the order. All qualified professionals rendering therapy must document the appropriate history. Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time or the need to establish a safe and effective maintenance program. documented in the medical record. the medical record shall contain that information outlined in the following pages. This documentation should establish the variables that influence the patient’s condition. Outpatient therapy must be under the care of a physician/NPP. type of treatment. An order (sometimes called a referral) for therapy service. Certification is the physician’s/NPP’s approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.

97026. the evaluation may be reimbursed if the medical necessity for the evaluation is clearly documented. The plan (also known as a plan of care or plan of treatment) must be established before treatment begins. when compared. The plan is established when it is developed (e. (Refer to the Indications and Limitations of Coverage and/or Medical Necessity section in this manual. no further certification of the plan is required. Rev. per patient) by discipline for CPT codes. Establishing the Plan The services must relate directly and specifically to a written treatment plan as described in this section. Payment is dependent on the certification of the plan of care rather than the order. 01/2012 35 Conditions of Coverage . If the signed order includes a plan of care (refer to Certification and Recertification within the Conditions of Coverage section in this manual). but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.MEDICARE PART B Therapy Services assessment documented in progress notes should describe objective measurements which. written or dictated). When both a modality/procedure and an evaluation service are billed. Signature and professional identity of the person who established the plan and the date it was established must be recorded with the plan. provides evidence of both the need for care and that the patient is under the care of a physician. 97034) on the same date of service must be available for review and show that all were needed toward the restoration of function. per date of service. show improvement in function or decrease in severity or rationalization for an optimistic outlook to justify continued treatment. The total number of timed minutes must be documented in the medical record..g.) When therapy services are billed as “incident to” physician/NPP services. if it is documented in the medical record. 97024. the certification requirements are met when the physician certifies the plan of care. A dated notation of a verbal order to certify the plan of care should be made in the patient’s medical record. Documentation supporting the medical necessity for multiple heating modalities (codes 97018. However.        Outpatient Therapy Must Be Under the Care of a Physician/NonPhysician Practitioner (NPP) (Orders/Referrals and Need for Care) An order (sometimes called a referral) for therapy service. per discipline. There are allowed unit limitations (once per provider. the requirement for direct supervision by the physician/NPP and other “incident to” requirements must be met even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings. Evidence considered necessary to justify delayed certification should be maintained by the supplier of services.

Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who establishes the plan. Payment for services provided before a plan is established may be denied. Contents of Plan The plan of care shall contain. Outpatient therapy services shall be furnished under a plan established by one of the following:  A physician/NPP (consultation with the treating Physical Therapist (PT).. 01/2012 36 Conditions of Coverage . It is also acceptable to combine the plans of care into one plan covering both conditions if one or the other referring physician/NPP is willing to certify the plan for both conditions. Separate progress reports referencing each plan of care may also be written at the discretion of the treating clinician or at the request of the certifying physician/NPP. The treatment notes continue to require timed code treatment minutes and total treatment time and need not be separated by plan. Progress reports should be combined if it is possible to make clear that the goals for each plan are addressed. MD.g. Rev. Only a physician may establish a plan of care in a Comprehensive Outpatient Rehabilitation Facility (CORF)). Occupational Therapist (OT) or Speech-Language Pathologist (SLP) is recommended. It is appropriate that treatment begins when a plan is established.MEDICARE PART B Therapy Services The signature and professional identity (e.  Long-term treatment goals. Two Plans It is acceptable to treat under two separate plans of care when different physicians/ NPPs refer a patient for different conditions. Treatment Under a Plan The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.  The SLP who will provide the speech-language pathology services. but shall not be required by contractors. the following information:  Diagnoses. The plan may be entered into the patient’s therapy record either by the person who established the plan or by the provider or supplier’s staff when they make a written record of that person’s verbal orders before treatment is begun. Therapy may be initiated by qualified professionals or qualified personnel based on a dictated plan.  The PT who will provide the physical therapy services. Establishing the plan is not the same as certifying the plan. at minimum. OTR/L) of the person who established the plan and the date it was established must be recorded with the plan.  The OT who will provide the occupational therapy services.

amount. the type is assumed to be consistent with the therapy discipline (physical therapy. or the number of treatment sessions. a PT may not provide services under an occupational therapy plan of care. When more than one discipline is treating a patient. The amount of treatment refers to the number of times in a day the type of treatment will be provided. when there is a single evaluation service. When a physician/NPP establishes a plan. speech-language pathology) ordered. both may be treating the patient for the same condition at different times in the same day for goals consistent with their own scope of practice. for this plan of care. the form of the plan and the number of plans incorporated into one document are not limited as long as the required information is present and related to each discipline separately. The type of treatment may be physical therapy. For example. or of the therapist who provided the evaluation. When episodes in the setting are short. documentation should state the clinical reasons progress cannot be shown. Goals should be measurable and pertain to identified functional impairments. occupational therapy. which may be attached and is considered incorporated into the plan. goals. etc. There shall be different plans of care for each type of therapy discipline. If a scheduled holiday occurs on a treatment day that is part of the plan. measurable goals may not be achievable. where appropriate. If the episode of care is anticipated to extend beyond the 90 calendar-day limit Rev. one treatment is assumed. it is appropriate to omit that treatment day unless the clinician who is responsible for writing progress reports determines that a brief. However. the type may be a description of a specific treatment or intervention. or. the plan must specify the type (physical therapy. However. The duration is the number of weeks. independently. duration and frequency of therapy services. the long-term goals may be specific to the part of the episode that is being certified.. 01/2012 37 Conditions of Coverage . occupational therapy or speechlanguage pathology. The frequency refers to the number of times in a week the type of treatment is provided. For example. speech-language pathology) of therapy planned. When the episode is anticipated to be long enough to require more than one certification. temporary pause in the delivery of therapy services would adversely affect the patient’s condition. but the type is not specified. each must establish a diagnosis. When amount is not specified. balancing the best achievable outcome with the appropriate resources.MEDICARE PART B Therapy Services  Type. When frequency is not specified. Long-term treatment goals should be developed for the entire episode of care in the current setting. The plan of care shall be consistent with the related evaluation. one treatment session a day is assumed. occupational therapy. The plan should strive to provide treatment in the most efficient and effective manner.

or may result in earlier discharge than routine treatment three times a week for four weeks. but should be considered with other factors such as condition.” Changes to the frequency may be made based on the clinician’s clinical judgment and do not require recertification of the plan unless requested by the physician/NPP. Instead. specific treatment interventions. then once a week for the last two weeks. For example. procedures. 01/2012 38 Conditions of Coverage .MEDICARE PART B Therapy Services for certification of a plan. the ability of the patient and/or caregiver to do more independent self management as treatment progresses. it is desirable. in accordance with good practice. The clinician should consider any comorbidities. modalities or techniques and the amount of each. although not required. the exact number of treatments per frequency level is not required to be projected in the plan. For example. progress and treatment type to provide the most effective and efficient means to achieve the patients’ goals. It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward an independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time. When tapered frequency is planned. Depending on the individual’s condition. Example: Amount. three times a week tapered to once a week over six weeks. The above policy describes the minimum requirements for payment. goals and duration for the current episode of care. the beginning and end frequencies shall be planned. and any other factors related to frequency and duration of treatment. medically necessary. Also. Example: Treatment may be provided three times a week for two weeks. It is anticipated that clinicians may choose to make their plans more specific. they may include these optional elements: short-term goals. because the changes should be made based on assessment of daily progress. tissue healing. such treatment may result in better outcomes. it may be clinically appropriate. notations in the medical record of beginning date for the plan are recommended but not required to assist Medicare contractors in determining the dates of services for which the plan was effective. most efficient and effective to provide short-term intensive treatment or longer-term and less-frequent treatment depending on the individuals’ needs. frequency and duration may be documented as “once daily. then two times a week for the next two weeks. that the clinician also estimate the duration of the entire episode of care in this setting. The frequency or duration of the treatment may not be used alone to determine medical necessity. Rev.

when the goals remain unchanged.g. While the physician/NPP may change a plan of treatment established by the therapist providing such services. making revision of long-term goals necessary.  The registered professional nurse or physician/NPP on the staff of the facility pursuant to the verbal orders of the physician/NPP or therapist. This shall be reported to the physician/NPP responsible for the patient’s treatment prior to the next certification. neuromuscular re-education) and modalities (e. the therapist may delete a specific intervention from the plan of care prior to physician/NPP approval. but are the means by which long. or a modification of short-term goals to adjust for improvements made toward the same long-term goals. 01/2012 39 Conditions of Coverage . the therapist may not significantly alter a plan of treatment established or certified by a physician/NPP without his documented written or verbal approval.  The qualified PT (in the case of physical therapy). A change in long-term goals (for example if a new condition was to be treated) would be a significant change. If a patient has achieved a goal and/or has had no response to a treatment that is part of the plan. An insignificant alteration in the plan would be a change in the frequency or duration due to the patient’s illness. It is not appropriate for a physician/NPP to certify a plan of care if the patient was not under the care of some physician/NPP at the time of Rev.and short-term goals are obtained.g.MEDICARE PART B Therapy Services Changes to the Therapy Plan Changes are made in writing in the patient’s record and signed by one of the following professionals responsible for the patient’s care:  The physician/NPP. Only when the patient’s condition changes significantly. Changes to procedures and modalities do not require physician signature when they represent adjustments to the plan that result from a normal progression in the patient’s disease or condition or adjustments to the plan due to lack of expected response to the planned intervention..  The qualified SLP (in the case of speech-language pathology services).. ultrasound) are not goals. Certification and Recertification Method and Disposition of Certifications Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. Procedures (e. Physician/NPP certification of the significantly modified plan of care shall be obtained within 30 days of the initial therapy treatment under the revised plan.  The qualified OT (in the case of occupational therapy services). is a physician’s/NPP’s signature required on the change (long-term goal changes may be accompanied by changes to procedures and modalities).

TrailBlazer may consider evidence of diligence in providing the plan to the Rev. The certification should be retained in the clinical record and available if TrailBlazer requests it.g. The certification must relate to treatment during the interval on the claim. the therapist should forward the plan to the physician as soon as it is established. a physician’s progress note.g.. the date the certification is signed is important only to determine if it is timely or delayed. facility. or within 30 days of the initial therapy treatment. physician/NPP or therapist) should obtain certification as soon as possible after the plan of care is established unless the requirements of delayed certification are met. Initial Certification of Plan The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of the certification requirements noted above for the duration of the plan of care. this new certification takes the place of any previous certification. contractors shall accept the order as certification of continued treatment for two weeks under the same plan of care. The initial treatment includes the evaluation that resulted in the plan. “As soon as possible” means the physician/NPP shall certify the initial plan as soon as it is obtained. If the new certification is for less treatment than previously planned and certified. or a plan of care that is signed and dated during the interval of treatment by a physician/NPP and indicates the physician/NPP is aware the therapy service is or was in progress and the physician/NPP makes no record of disagreement with the plan when there is evidence the plan was sent (e. 01/2012 40 Conditions of Coverage . Unless there is reason to believe the plan was not signed appropriately. for example. Timing of Initial Certification The provider or supplier (e. to the office) or is available in the record (e. or it is not timely. or 90 calendar days from the date of the initial treatment.g. Acceptable documentation of certification may be. The format of all certifications and recertifications and the method by which they are obtained is determined by the individual facility and/or practitioner.. of the institution that employs the physician/NPP) for the physician/NPP to review.MEDICARE PART B Therapy Services the treatment or if the patient did not require the treatment. Since delayed certification is allowed. Example: If during the course of treatment under a certified plan of care a physician sends an order for continued treatment for two more weeks. Since payment may be denied if a physician does not certify the plan. At the end of the two weeks of treatment (which might extend more than two calendar weeks from the date the order/certification was signed) another certification would be required if further treatment was documented as medically necessary. a physician/NPP order. whichever is less.. no further evidence that the patient was under the care of a physician/NPP and that the patient needed the care is required.

which required recertification every 30 calendar days. Certifications signed on or prior to December 31. Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident.MEDICARE PART B Therapy Services physician during review in the event of a delayed certification. and dated in the 30 days following the first day of treatment (including evaluation). Physician/NPP Options for Certification A physician/NPP may certify or recertify a plan for whatever duration of treatment the physician/NPP determines it is appropriate. 2008. It is not required that the same physician/NPP who participated initially in recommending or planning the patient’s care certify and/or recertify the plans. Recertification is not required if the duration of the initially certified plan of care is more than the duration (length) of the entire episode of treatment. Many episodes of therapy treatment last less than 30 calendar days. If the order to certify is verbal. unless they are delayed. it must be followed within 14 days by a signature to be timely. Therefore. it is expected that the physician/NPP should certify a plan that appropriately estimates the duration of care for the individual. by signature or verbal order. Physicians/NPPs may require that the patient make a physician/NPP visit for an examination if. as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. follow the rule in effect at that time. Treatment beyond the duration certified by the physician/NPP requires that a plan be recertified for the extended duration of treatment. Review of Plan and Recertification The timing of recertification changed on January 1. If the therapist writes a plan of care for a duration that is more or less than the duration approved by the physician/NPP. then the physician/NPP would document a change to the duration of the plan and certify it for the duration the physician/NPP finds appropriate (up to 90 days). 2008. or at least every 90 days after initiation of treatment under that plan. It is possible that patients will be discharged by the therapist before the end of the estimated treatment duration because some will improve faster than estimated and/or some were successfully progressed to an independent home program. 01/2012 41 Conditions of Coverage . Certifications signed on or after January 1. A dated notation of the order to certify the plan should be made in the patient’s medical record. 2007. in the professional’s judgment. up to a maximum of 90 calendar days. follow the rules in this section. the visit is needed prior to certifying the Rev. Timely certification of the initial plan is met when physician/NPP certification of the plan is documented. even if it is less than 90 days. Payment and coverage conditions require that the plan must be reviewed.

progress notes.MEDICARE PART B Therapy Services plan. For example. It is not intended that needed therapy be stopped or denied when certification is delayed. However. Delayed certification and recertification requirements shall be deemed satisfied where. services will not be considered reasonable and necessary due to lack of a certified plan. not to exceed 90 calendar days from the initial therapy treatment. Chiropractors may not certify or recertify plans of care for therapy services. a physician/NPP makes a certification accompanied by a reason for the delay.. requests for certification or signed statement of a physician/NPP) indicating need for care and that the patient was under the care of a physician at the time of the treatment.g. the physician should certify a plan only until the date of the visit. Certifications are acceptable without justification for 30 days after they are due. TrailBlazer may request such documentation for delayed certifications if it is required for review. Certifications are timely when the initial certification (or certification of a significantly modified plan of care) is dated within 30 calendar days of the initial treatment under that plan. 01/2012 42 Conditions of Coverage . Medicare does not require a visit unless the National Coverage Determination (NCD) for a particular treatment requires it. Physicians/NPPs should indicate their requirement for visits. Recertification is timely when dated during the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan. at any later date. Delayed certification should include one or more certifications or recertifications on a single signed and dated document. Delayed Certification Certifications are required for each interval of treatment based on the patient’s needs. the provider or supplier may choose to submit with the delayed certification some other documentation (e. Restrictions on Certification Certifications and recertifications by doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law. Optometrists may order and certify only low-vision services. The delayed certification of otherwise covered services should be accepted unless TrailBlazer has reason to believe there was no physician involved in the patient’s Rev. After that date. a certification may be delayed because the physician did not sign it or the original was lost. whichever is less. an order. Delayed certifications should include any evidence the provider or supplier considers necessary to justify the delay. preferably on an order preceding the treatment or on the plan of care that is certified. or during the planned treatment. Physicians/NPPs should not sign a certification if they require a visit and a visit was not made. In the case of a long-delayed certification (longer than six months). If the physician wishes to restrict the patient’s treatment beyond a certain date when a visit is required. telephone contact.

that service might be denied for lack of the required certification. in good practice. documentation should continue to indicate that therapy during the delay is medically necessary. Certification is a statutory requirement in Social Security Act 1835(a)(2) – (“periodic review” of the plan). meeting notes. be reviewed and would indicate therapy treatment is in progress. as it would for any treatment. and a new plan of care for continued treatment after March 30 is developed or signed by a therapist on April 15 and that plan is subsequently certified. If a certified plan of care ends March 30. Rev. physician/NPP attended meeting.MEDICARE PART B Therapy Services care or treatment did not meet the patient’s need (and therefore. documentation of therapist/physician/NPP discussion of the plan. including the treatment that preceded the date of the certification unless the physician/NPP indicates otherwise. the denial shall be overturned. 01/2012 43 Conditions of Coverage . that certification may be considered delayed and acceptable effective from the first treatment date after March 30 for the frequency and duration as described in the plan. the certification was signed inappropriately). Of course. chart notes. note. or physician/NPP services during which the medical record or the patient’s history would. Payment should not be denied. The certification of the physician/NPP is interpreted as involvement and approval of the ongoing episode of treatment. Subsequent certifications of plans for continued treatment for the same condition in the same patient may indicate physician certification of treatment that occurred between certification dates. when there is evidence that a physician approved needed treatment. or other indication there was a physician/NPP involved in the case. Example: Example: Denials Due to Certification Denial for payment that is based on absence of certification is a technical denial. If an appropriate certification is later produced. even if the signature for one of the plans in the episode is delayed. even when certified two years after treatment. documentation of sending the plan to any physician/NPP. Example: Payment should be denied if there is a certification signed two years after treatment by a physician/NPP who has/had no knowledge of the patient when the medical record also shows no order. Example: A patient is treated and the provider/supplier cannot produce (upon TrailBlazer’s request) a plan of care (timely or delayed) for the billed treatment dates certified by a physician/NPP. requests for certification. which means a statutory requirement has not been met. documentation of discussion of the plan with a physician/NPP. correspondence with a physician/NPP. such as an order.

if the service is provided by a supplier (in the office of the physician/NPP or therapist).MEDICARE PART B Therapy Services In the case of a service furnished under a provider agreement. a technical denial due to absence of a certification results in beneficiary liability. it is recommended that the patient be made aware of the need for certification and the consequences of its absence. Rev. A technical denial decision may be reopened by TrailBlazer or reversed on appeal as appropriate. However. For that reason. if delayed certification is later produced. 01/2012 44 Conditions of Coverage . the provider is precluded from charging the beneficiary for services denied because of missing certification.

progress indicates the care is effective in rehabilitation of function). but no less than the frequency required in Medicare policy:  Evaluation/Plan of Care (may be one or two documents). Documentation Required The following types of documentation of therapy services are expected to be submitted in response to any requests for documentation unless TrailBlazer requests otherwise. State or local laws and policies. 01/2012 45 General Documentation . Documentation must be legible. TrailBlazer shall consider the entire record when reviewing claims for medical necessity so that the absence of an individual item of documentation does not negate the medical necessity of a service when the documentation as a whole indicates the service is necessary. the American Occupational Therapy Association or the American Speech-Language Hearing Association. Services are medically necessary if the documentation indicates they meet the requirements for medical necessity including that they are skilled.  Certification (physician/NPP approval of the plan) and recertification when Rev. Medicare requires that the services billed be supported by documentation that justifies payment. provided by clinicians (or qualified professionals when appropriate) with the approval of a physician/Non-Physician Practitioner (NPP) and are safe and effective (i. Documentation must comply with all legal/regulatory requirements applicable to Medicare claims. The documentation guidelines identify the minimal expectations of documentation by providers. or the policies of the profession. rehabilitative services. services must be covered therapy services provided according to the requirements in Medicare manuals. Document as often as the clinician’s judgment dictates. The timelines are minimum requirements for Medicare payment.MEDICARE PART B Therapy Services GENERAL DOCUMENTATION Therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services. In general..e. Documentation must comply with all legal/regulatory requirements applicable to Medicare claims. the practice or the facility may be more stringent. It is encouraged but not required that narratives that specifically justify the medical necessity of services be included to support approval when those services are reviewed. Additional documentation not required by Medicare is encouraged when it conforms to state or local law or to professional guidelines of the American Physical Therapy Association. suppliers or beneficiaries submitting claims for payment of therapy services to the Medicare program. Medicare requires that the services billed be supported by documentation that justifies payment. relevant and sufficient to justify the services billed. Include the initial evaluation and any re-evaluations relevant to the episode being reviewed.

if applicable) when records are requested after the reports are due. Document Information to Meet Requirements In documenting records. (At least once every 10 treatment days or at least once during each certification interval. TrailBlazer may request further information to be included in these documents concerning specific cases under review when that information is relevant but not submitted with records. A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands the reasoning for services that are more extensive than is typical for the condition treated. Dictated Documentations For Medicare purposes. a progress report would be required at the end of the month. clinicians must be familiar with the requirements for covered and payable outpatient therapy services as described in the manuals.MEDICARE PART B Therapy Services records are requested after the certification/recertification is due. Certification (and recertification of the plan when applicable) are required for payment and must be submitted when records are requested after the certification or recertification is due. Example: If treatment began on the first of the month at a frequency of twice a week. Progress reports (including discharge notes.    Limits on Requirements TrailBlazer does not require more specific documentation unless other Medicare manual policies require it. Dates for Documentation The date the documentation was made is important only to establish the date of the initial plan of care because therapy cannot begin until the plan is established unless treatment is performed or supervised by the same clinician who establishes the plan. The qualified professional may edit and electronically sign the documentation at a later date. 01/2012 46 General Documentation . Rev. TrailBlazer may require the progress report that describes that month of treatment be dated not more than one week after the end of the month described in the report. dictated therapy documentation is considered completed on the treatment day it was dictated. A separate statement is not required if the record justifies treatment without further explanation.) Treatment notes for each treatment day (may also serve as progress reports when required included information is in the notes). whichever is less. However. TrailBlazer may require that treatment notes and progress reports be entered into the record within one week of the last date to which the progress report or treatment note refers.

frequency. qualified personnel.  A therapist’s skill may also be required for safety reasons if an unstable fracture requires the skill of a therapist to do an activity that might otherwise be done independently by the patient at home. but must apply the skills of a therapist by actively participating in the treatment of the patient during each progress report period. Note that regression and plateaus can happen Rev. conference. a therapist’s skills may be documented. the expertise. by the clinician’s descriptions of their skilled treatment. In addition. the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day. After the patient is judged safe for independent use of these compensatory techniques. intensity and duration for the individual needs of the patient.  Services are of appropriate type.  Documentation should establish through objective measurements that the patient is making progress toward goals. o Although not required. knowledge. decision-making and abilities of a therapist that assistants. for example.  Clinicians and contractors shall determine typical services using published professional literature and professional guidelines. but are payable if the individual patient benefits from medically necessary services. caretakers or the patient cannot provide independently. for example. o Physician/NPP care shall be documented by physician/NPP certification (approval) of the plan of care.MEDICARE PART B Therapy Services For example.  Documentation should establish the variables that influence the patient’s condition. 01/2012 47 General Documentation . Services that exceed those typically billed should be carefully documented to justify their necessity. or changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task. team meeting notes and correspondence. for example. The fact that services are typically billed is not necessarily evidence that the services are typically appropriate.  Services require the skills of a therapist. clinical judgment. A clinician may not merely supervise. the records should justify:  The patient is under the care of a physician/NPP. The skill of a therapist might be required for a patient learning compensatory swallowing techniques to perform cervical auscultation and identify changes in voice and breathing that might signal aspiration. Services must not only be provided by the qualified professional or qualified personnel. especially those factors that influence the clinician’s decision to provide more services than are typical for the individual’s condition. Also. order/referral. some services or episodes of treatment should be less than those typically billed when the individual patient reaches goals sooner than is typical. the skill of a therapist is not required to feed the patient or check what was consumed. but they must require. other evidence of physician/NPP involvement in the patient’s care may include.

as described in documentation (usually in the evaluation. severity. cognitive ability. the patient also needs the services. so changes in objective and sometimes to subjective measures of improvement also help establish the need for services. time since onset/acuity. age. prognosis. The use of scientific evidence obtained from professional literature and sequential measurements of the patient’s condition during treatment is encouraged to support the potential for continued improvement that may justify the patient’s need for therapy. Patients who need therapy generally respond to therapy. Needs of the Patient When a service is reasonable and necessary. psychological and social stability. Rev. It is recommended that the reasons for lack of progress be noted and the justification for continued treatment be documented if treatment continues after regression or plateaus. but in general. complicating factors. Contractors determine the patient’s needs through knowledge of the individual patient’s condition and any complexities that impact that condition. 01/2012 48 General Documentation . they relate to factors such as the patient’s diagnoses. selfefficacy/motivation. re-evaluation and progress report). Factors that contribute to need vary. and/or medical.MEDICARE PART B Therapy Services during treatment.

the American Occupational Therapy Association or the American Speech-Language and Hearing Association as guidelines. evaluation. re-evaluation and assessment or establish a diagnosis or plan of care. A description might include.MEDICARE PART B Therapy Services EVALUATION/RE-EVALUATION AND PLAN OF CARE Evaluation The initial evaluation. (FOTO). use a condition description similar to the appropriate ICD-9-CM code. Rev. o Results of one of the following four measurement instruments are recommended. Evaluation shall include:  A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. Inc. date of onset and current function. and for speech-language pathology. Utilize the guidelines of the American Physical Therapy Association. describe the impact of the conditions and complexities on the prognosis and/or the plan for treatment such that it is clear to the contractor who may review the record that the services planned are appropriate for the individual. both a medical diagnosis (obtained from a physician/Non-Physician Practitioner (NPP)) and an impairment-based treatment diagnosis related to treatment are relevant. The diagnosis should be specific and as relevant to the problem to be treated as possible. objective measurements or observations made by a Physical Therapist Assistant (PTA) or Occupational Therapist Assistant (OTA) within their scope of practice. For example the medical diagnosis made by the physician is Cerebrovascular Accident (CVA).  Patient Inquiry by Focus on Therapeutic Outcomes. should document the necessity for a course of therapy through objective findings and subjective patient selfreporting. For physical therapy and occupational therapy. where it is not obvious. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others. Only a clinician may perform an initial examination. A clinician may include. it may be hemiparesis. but the clinician must actively and personally participate in the evaluation or re-evaluation. When a diagnosis is not allowed. but not required:  National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association. and not as policy. Include all conditions and complexities that may impact the treatment. In many cases. Documentation of the evaluation should list the conditions and complexities and. be sure to include the body part evaluated. For occupational therapy. the premorbid function. for example. however. it may be dysphagia. as part of the evaluation or re-evaluation. the treatment diagnosis or condition description for physical therapy may be abnormality of gait. depending on his scope of practice. or the plan of care including an evaluation. The treatment diagnosis may or may not be identified by the therapist. 01/2012 49 Evaluation/Re-Evaluation and Plan of Care .

radiation therapy. time  Rev. Physical Therapist (PT). The beneficiary has. as applicable. etc. contractors shall take this documented information into account to determine whether services are reasonable and necessary. Since published research supports its impact on the need for treatment. Occupational Therapist (OT)..g.MEDICARE PART B Therapy Services   Activity Measure – Post Acute Care (AM-PAC). treatment notes. nutritional/dietetic services.  Generalized or multiple conditions. or conditions affecting multiple sites and these conditions will directly and significantly impact the rate of recovery.  Mental or cognitive disorder. physician. Speech-Language Pathologist (SLP). nurse.  Identification of durable medical equipment needed for this condition.  Identification of factors that impact severity including. or generalized musculoskeletal conditions. Documentation supporting illness severity or complexity including. another disease or condition being treated. If results of one of the four instruments above are not recorded.  Identification of the number of medications the beneficiary is taking (and type if known). This information may be incorporated into a test instrument or separately reported within the required documentation. Documentation should indicate how the progress was affected by the complexity. the severity of the patient’s condition as reported on a functional measurement tool may be so great as to suggest extended treatment is anticipated.g. If it changes.. in addition to the primary condition being treated. When it is provided.:  Identification of other health services concurrently being provided for this condition (e. such dysrhythmias may so directly and significantly affect the pace of progress in treatment for other conditions as to require an exception to caps for necessary services. OPTIMAL by Cedaron through the American Physical Therapy Association. the record shall contain instead. progress reports and/or in a separate record. age. Or. respiratory therapy. chemotherapy.). describe why or how. e. but in some patients. For example: Cardiac dysrhythmia is not a condition for which a therapist would directly treat a patient.g. social services. information in the following indented bullets may also be included with the results of the above four instruments in the evaluation report. 01/2012 50 Evaluation/Re-Evaluation and Plan of Care .  If complicating factors (complexities) affect treatment. psychology. The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will directly and significantly impact the rate of recovery. e. the following information indicated by an asterisk (*) and should contain (but is not required to contain) all of the following. chiropractic. at the clinician’s discretion. update this information in the re-evaluation.

how typical/atypical are the symptoms of the diagnosed condition.  Record of a previous episode of therapy treatment from the same or different therapy discipline in the past year.  Who does beneficiary live with (or intend to live with) at the conclusion of this outpatient therapy episode? (e. indicate why. lives alone. 51 Evaluation/Re-Evaluation and Plan of Care     Rev. group home. cause of the condition. child/children. availability of an intervention/treatment known to be effective.MEDICARE PART B Therapy Services since onset. personal care attendant). Skilled Nursing Facility (SNF). Documentation supporting medical care prior to the current episode. including:  Record of discharge from a Part A qualifying inpatient. rented room. fair or poor?” If the beneficiary is unable to respond. other relative. predictability of progress.  Does the beneficiary require this outpatient therapy plan of care to return to a premorbid (or reside in a new) living environment?  Does the beneficiary require this outpatient therapy plan of care to reduce Activities of Daily Living (ADL) or Instrumental Activities of Daily Living (IADL) assistance to a premorbid level or to reside in a new level of living environment (document prior level of independence and current assistance needs)? *Documentation required to indicate objective. if any (or document none). would you say that your health is excellent. unrelated person(s).g. private home.g.. specifically:  The beneficiary’s response to the following question of self-related health: “At the present time.. Documentation required to indicate beneficiary health related to quality of life. board and care apartment. very good. or home health episode within 30 days of the onset of this outpatient therapy episode.  Identification of whether beneficiary was treated for this same condition previously by the same therapy discipline (regardless of where prior services were furnished). private apartment. 01/2012 . Documentation required to indicate beneficiary social support including. specifically:  Where does the beneficiary live (or intend to live) at the conclusion of this outpatient therapy episode? (e. stability of symptoms. measurable beneficiary physical function including:  Functional assessment individual item and summary scores (and comparisons to prior assessment scores) from commercially available therapy outcomes instruments other than those listed above. spouse/significant other. assisted living. SNF).

frequency. A determination that treatment is not needed. 01/2012 52 Evaluation/Re-Evaluation and Plan of Care . a referral/order and evaluation are the only required documentation. Re-evaluations are usually focused on the current treatment and might not be as extensive as initial evaluations. or in states where a therapist may not diagnose. The goal.    When the Evaluation Serves as a Plan of Care When an evaluation is the only service provided by a provider/supplier in an episode of treatment. Evaluation minutes are untimed and are part of the total treatment minutes.MEDICARE PART B Therapy Services Functional assessment scores (and comparisons to prior assessment scores) from tests and measurements validated in the professional literature that are appropriate for the condition/function being measured. Re-Evaluations Re-evaluations shall be included in the documentation sent to TrailBlazer when a reevaluation has been performed. a physician referral/order or certification of the evaluation is required for payment of the evaluation. making a professional judgment about continued care. If the patient presented for evaluation without a referral or order and does not require treatment. or if treatment is needed.  Other measurable progress toward identified goals for functioning in the home environment at the conclusion of this therapy episode of care. but minutes of evaluation shall not be included in the minutes for timed codes reported in the treatment notes. Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated when they provide further information to supplement measurement tools. A re-evaluation is not a routine. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient. the evaluation serves as the plan of care if it contains a diagnosis. recurring service but is focused on evaluation of progress toward current goals. A formal reevaluation is covered only if the documentation supports the need for further tests and Rev. intensity and duration of treatment are implied in the diagnosis and one-time service. Therefore. a prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care. a description of the condition from which a diagnosis may be determined by the referring physician/NPP. The time spent in evaluation shall not also be billed as treatment time. when evaluation is the only service. The referral/order of a physician/NPP is the certification that the evaluation is needed and the patient is under the care of a physician. Continuous assessment of the patient’s progress is a component of ongoing therapy services and is not payable as a re-evaluation. modifying goals and/or treatment or terminating services.

the clinician may Rev. either the physician/NPP who provides or supervises the services. or by the therapist who provides the services and supervises an assistant. Timing The minimum progress report period shall be at least once every 10 treatment days or at least once during each 30 calendar days. modifying goals and/or treatment or terminating services. a significant change in the patient’s condition or failure to respond to the therapeutic interventions outlined in the plan of care. the 10th treatment day or the 30th calendar day of the episode of treatment. that is. or for the use of the physician or the treatment setting at which treatment will be continued. whichever is less. OT or SLP. Re-evaluation requires the same professional skills as evaluation. The next treatment day begins the next reporting period. for a patient evaluated on Monday. TrailBlazer shall determine the necessity of services based on the delivery of services as directed in the plan and as documented in the treatment notes and progress report. For Medicare payment purposes. The day beginning of the first reporting period is the first day of the episode of treatment regardless of whether the service provided on that day is an evaluation. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care. re-evaluation or treatment.MEDICARE PART B Therapy Services measurements after the initial evaluation. For example. Regardless of the date on which the report is actually written (and dated). Indications for a re-evaluation include new clinical findings. and being treated five times a week. information required in progress reports shall be written by a clinician. Progress Report The progress report provides justification for the medical necessity of treatment. It is not required that the referring or supervising physician/NPP sign the progress reports written by a PT. on weekdays: On October 5 (before it is required). Plan of Care The evaluation and plan may be reported in two separate documents or a single combined document. refer to “Establishing the Plan Within the Conditions of Coverage” section in this manual. October 1. 01/2012 53 Evaluation/Re-Evaluation and Plan of Care . A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met. The minutes for re-evaluation are documented in the same manner as the minutes for evaluation. the end of the progress report period is either a date chosen by the clinician. The progress report period requirements are complete when both the elements of the progress report and the clinician’s active participation in treatment have been documented. use the evaluation code. CPT does not define a re-evaluation code for speech-language pathology. whichever is shorter. For requirements.

Particularly where the patient’s medical status. 01/2012 54 Evaluation/Re-Evaluation and Plan of Care . However. absences do not affect the requirement for a progress report at least once during each progress report period. The clinical judgment demonstrated in frequent reports may help justify that the skills of a therapist are being applied. October 5 ends the reporting period and the next treatment on Monday. when the clinician has not yet provided the required active participation during that reporting period. or appropriate tapering of frequency due to expected progress toward goals. Absences Holidays. update goals. Delayed Reports If the clinician has not written a progress report before the end of the progress reporting period. For days when a patient does not encounter qualified professional or qualified personnel for treatment. describe the skilled treatment. the next report is required to cover October 8 through October 19. and inform physician/NPPs or other staff. 2–4 times a month). document progress and justify the continued necessity for skilled care. It is not necessary to include in this treatment note any information already recorded in prior treatment notes or progress reports.g. a progress report is still required. sick days or other patient absences may fall within the progress report period. the requirements of the progress report period are incomplete. Rev.MEDICARE PART B Therapy Services choose to write a progress report for the last week’s treatment (from October 1 to October 5). If the patient is absent unexpectedly at the end of the reporting period. it shall be written within seven calendar days after the end of the reporting period. begins the next reporting period. which would be 10 treatment days. but without the clinician’s active participation in treatment. more frequent progress reports can differentiate rehabilitative from maintenance treatment. (Consideration of the case in preparation for a report may lead the therapist to request early recertification. results in limited frequency (e. Also. October 8. documentation of the delayed active participation shall be entered in the treatment note as soon as possible. evaluation or re-evaluation do not count as treatment days. However. In many settings. and there may be several reports between recertifications). the treatment note shall document the clinician’s guidance to the assistant or qualified personnel to justify that the skills of a therapist were required during the reporting period. and that services are medically necessary. It should be emphasized that the dates for recertification of plans of care do not affect the dates for required progress reports. If the clinician does not choose to write a report for the next week. each report does not require recertification of the plan.. If the clinician did not participate actively in treatment during the progress reporting period. weekly progress reports are voluntarily prepared to review progress. The treatment note shall explain the reason for the clinician’s missed active participation.

When unexpected discontinuation of treatment occurs. the revised plan of care accompanied by the progress report shall be recertified by a physician/NPP. the progress report shall be written and signed by the therapist who provides the services. then a separate progress report is not required. covered and payable. Therefore. Progress Reports for Services Billed ‘Incident to’ a Physician’s Service The policy for “incident to” services requires. at the discretion of the clinician. Documenting Clinician Participation in Treatment in the Progress Report Verification of the clinician’s required participation in treatment during the progress reporting period shall be documented by the clinician’s signature on the treatment note and/or on the progress report. for example. Also. supervision and reporting requirements for supervising physicians’/NPPs’ supervising staff are the same as those for PTs and OTs supervising PTAs and OTAs with certain exceptions noted below. elements of the progress report may be incorporated into a revised plan of care when one is indicated. the ordering or supervising physician/NPP must personally provide at least one treatment session during each progress reporting period and sign the progress report. or even daily. Early Reports Often. 01/2012 55 Evaluation/Re-Evaluation and Plan of Care . Although the progress report written by a therapist does not require a physician/NPP signature when written as a stand-alone document.MEDICARE PART B Therapy Services The contractor shall make a clinical judgment whether continued treatment by assistants or qualified personnel is reasonable and necessary when the clinician has not actively participated in treatment for longer than one reporting period. progress reports are written weekly. When the services “incident to” a physician are provided by qualified personnel who are not therapists. the physician’s initial service. contractors shall not require a clinician’s participation in treatment for the incomplete Rev. If each element required in a progress report is included in the treatment notes at least once during the progress reporting period. Clinicians are encouraged. Elements of progress reports may be written in the treatment notes if the provider/supplier or clinician prefers. but not required to write progress reports more frequently than the minimum required to allow anyone who reviews the records to easily determine that the services provided are appropriate. direct supervision of therapy services and subsequent services of a frequency that reflect his active participation in and management of the course of treatment. Judgment shall be based on the individual case and documentation of the application of the clinician’s skills to guide the assistant or qualified personnel during and after the reporting period. When a therapy service is provided by a therapist supervised by a physician/NPP and billed “incident to” the services of the physician/NPP.

Reports written by assistants are not complete progress reports. if they are relevant. The record should be reviewed and organized so that the required documentation is ready for presentation to the contractor if requested.  Objective reports of the patient’s subjective statements. reports written by assistants are part of the record and need not be copied into the clinician’s report. or for dictated documentation.  Date that the report was written (not required to be within the reporting period). a separate discharge note written by a therapist is not required. In that case. Progress reports written by assistants supplement the reports of clinicians and shall include:  Date of the beginning and end of the reporting period to which this report refers. Discharge Note (or Discharge Summary) The discharge note (or discharge summary) is required for each episode of outpatient treatment. The clinician must write a progress report during each progress reporting period regardless of whether the assistant writes other reports. 01/2012 56 Evaluation/Re-Evaluation and Plan of Care .  Signature and professional identification. In the case of a discharge anticipated within three treatment days of the progress report. The discharge note shall be a progress report written by a clinician. For Rev. for example. the clinician may provide objective goals which. it may summarize the entire episode of treatment or justify services that may have extended beyond those usually expected for the patient’s condition.MEDICARE PART B Therapy Services reporting period. and shall cover the reporting period from the last progress report to the date of discharge. In the case of a discharge unanticipated in the plan or previous progress report. will authorize the assistant or qualified personnel to discharge the patient. the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist and services were provided or supervised by a clinician. At the discretion of the clinician. In provider settings where the physician/NPP writes a discharge summary and the discharge documentation meets the requirements of the provider setting. However. when met. Clinicians should consider the discharge note the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed. the identification of the qualified professional who wrote the report and the date on which it was dictated. Assistant’s Participation in the Progress Report PTAs or OTAs may write elements of the progress report dated between clinician reports. the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified personnel. The discharge note shall include all treatment provided since the last progress report and indicate that the therapist reviewed the notes and agreed to the discharge. the discharge note may include additional information.

MEDICARE PART B Therapy Services example. the progress report of a clinician shall also include:  Assessment of improvement. and information in them is not required to be repeated in the report. but “patient ambulates 15 feet with maximum assistance” is objective.  Plans for continuing treatment. Preferably. If a body part is not specifically noted. if they occur. Since only long-term goals are required in the plan of care.).” Objective measurements (preferred) or description of changes in status relative to each goal currently being addressed in treatment. Note that assistants may not make clinical judgments about why progress was or was not made. 01/2012 57 Evaluation/Re-Evaluation and Plan of Care . it is assumed that the goals refer to the plan of care active for the current progress reporting period. When short-term goal changes are dictated to an assistant or to qualified personnel. Content of Clinician (Therapist. 1. The evaluation and plan of care are considered incorporated into the progress report. Any consistent method of identifying the goals may be used.  Changes to long. if a time interval for the treatment is not specifically stated. The identifier of a goal on the plan of care may not be changed during the episode of care to which the plan refers. and refused to complete the treatment session. discharge or an updated plan of care that is sent to the physician/NPP for certification of the next interval of treatment. reference to additional evaluation results and/or treatment plan revisions should be documented in the clinician’s progress report. Physician/Non-Physician Practitioner (NPP)) Progress Reports In addition to the requirements above for notes written by assistants. For example: “increasing strength” is not an objective measurement. Assistants may change goals only under the direction of a clinician. report the change. For example. A clinician. it is assumed the treatment is consistent with the evaluation and plan of care. extent of progress (or lack thereof) toward each goal. Rev.or short-term goals. an assistant on the order of a therapist or qualified personnel on the order of a physician/NPP shall add new goals with new identifiers or letters. etc. “The patient was not feeling well on 11/05/06. the progress report may be used to add. 3) and the short-term goals that relate to the long-term goals may be numbered and lettered (1. clinician’s name and date. Clinicians verify these changes by co-signatures on the report or in the clinician’s progress report (to modify the plan for changes in long-term goals). and that clinician’s signature verifies the change. but may report the progress objectively.B.A. change or delete short-term goals. Omit reference to a goal after a clinician has reported it to be met.  Descriptions shall make identifiable reference to the goals in the current plan of care. “Patient reports pain after 20 repetitions. the long-term goals may be numbered (1.” Or. 2.

Therapy is planned three times a week. 01/2012 58 Evaluation/Re-Evaluation and Plan of Care . Rev. Patient is on a restricted diet and wants to drink thick liquids. Improved to 80 percent of trials. 45-minute sessions. particularly when reports are written at the minimum frequency. CCC-SLP.2 – Dysphagia secondary to other late effects of CVA. for six weeks. Objective evidence consists of standardized patient assessment instruments. The progress report for 1/3/06 to 1/29/06 indicates: 1. Achieved. Mary Johns. for example. compliant with current restrictions. Long-term goal is to consume a mechanical soft diet with thin liquids without complications such as aspiration pneumonia. objective evidence or a clinically supportable statement of expectation that:  The patient’s condition has the potential to improve or is improving in response to therapy. but their use will enhance the justification for needed therapy. but may be appropriate when assessment suggests changes not anticipated in the original plan of care. spouse assists with practicing.MEDICARE PART B Therapy Services A re-evaluation should not be required before every progress report routinely.  There is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time. during and/or after treatment is recommended to quantify progress and support justifications for continued treatment. Comments: Highly motivated. Use of objective measures at the beginning of treatment.  Maximum improvement is yet to be attained. 2. Such tools are not required. Justification for treatment must include. Short-Term Goal 2: Patient will compensate for reduced laryngeal elevation by controlling bolus size to one-half teaspoon without cues 100 percent. Example: The Plan states diagnosis is 787. New Goal: “Patient will implement above strategies to swallow a sip of water without coughing for five consecutive trials. Short-Term Goal 1: Patient will improve rate of laryngeal elevation/timing of closure by using the super-supraglottic swallow on saliva swallows without cues on 90 percent of trials. outcome measurements tools or measurable assessments of functional outcome. Care must be taken to assure that documentation justifies the necessity of the services provided during the reporting period.

regardless of whether it is billed. it is not required that unbilled services that are not part of the total treatment minutes be recorded.g. for both timed and untimed codes. skilled treatment is documented. progress is documented. PT. with notation of phone consultations with Judy Jones. Total treatment time does not include time for services that are not billable (e. The treatment note is not required to document the medical necessity or appropriateness of the ongoing therapy services. Documentation of each treatment shall include the following required elements:  Date of treatment. The billing and the total timed-code treatment minutes must be consistent. rest periods). in language that can be compared with the billing on the claim to verify correct coding. show consistency with the plan or comply with state or local policies.” Note the provider is billing 92526 three times a week. Descriptions of skilled interventions should be included in the plan or the progress reports and are allowed. Documentation is required for every treatment day and every therapy service. as it is indicated in the billing.. although they may be included voluntarily to provide an accurate description of the treatment.e. Refer to the “Reporting Units of Service” sections in this manual for description of billing timed codes.  Identification of each specific intervention/modality provided and billed. consistent with the plan. PTA. because the unbilled timed services may impact the billing. Non-skilled interventions need not be recorded in the treatment notes as they are not billable. but contractors shall not require it. Total treatment time includes the minutes for timed-code treatment and untimedcode treatment. However. The format shall not be dictated by contractors and may vary depending on the practice of the responsible clinician and/or the clinical setting.MEDICARE PART B Therapy Services 1/29/06.. Specifics such as number of repetitions of an exercise and other details included in the plan of care need not be repeated in the treatment notes unless they are changed from the plan.  Total timed-code treatment minutes and total treatment time in minutes. The amount of time for each specific intervention/modality provided to the patient may also be recorded voluntarily. Record each service provided that is represented by a timed code. supervisor. the signature of Kathleen Smith. Treatment Note The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim. 01/2012 59 Evaluation/Re-Evaluation and Plan of Care . For Medicare purposes. when permitted by state and local Rev.  Signature and professional identification of the qualified professional who furnished or supervised the services and a list of each person who contributed to that treatment (i. notation of non-skilled treatment or report of activities performed by the patient or non-skilled staff may be reported voluntarily as additional information if they are relevant and not billed. but not required daily.

 Equipment provided. as determined by the policies of the provider/supplier. The signature and identification of the supervisor need not be on each treatment note unless the supervisor actively participated in the treatment. clinician added electrical stim. For example: The original plan was for therapeutic activities. another therapist. etc. the supervisor is not required to cosign the treatment note written by a qualified professional.  Adverse reaction to intervention.  Patient self-report. When the responsible supervisor is absent.).  Communication/consultation with other providers (e. any relevant information should be included in the progress report. Since a clinician must sign the progress report. the change must be recorded and justified on the medical record. either in the treatment note or the progress report. To address shoulder pain.MEDICARE PART B Therapy Services law).” Documentation of each treatment may also include the following optional elements to be mentioned only if the qualified professional recording the note determines they are appropriate and relevant. 01/2012 60 Evaluation/Re-Evaluation and Plan of Care . Since a clinician must be identified on the plan of care and the progress report. nurse. It is important that the total number of timed treatment minutes supports the billing of units on the claim. If a treatment is added or changed under the direction of a clinician during the treatment days between the interval progress reports. If these are not recorded daily. attending physician. the name and professional identification of the supervisor responsible for the treatment is assumed to be the clinician who wrote the plan or report. supervising clinician.. “On February 1. When the treatment is supervised without active participation by the supervisor.g. gait training and neuromuscular re-education.  Significant. and that the total treatment time reflects services billed as untimed codes. New exercises added or changes made to an exercise program help justify that the services are skilled. the presence of a similarly qualified supervisor on the clinic roster for that day is sufficient documentation and it is not required that the substitute supervisor sign or be identified in the documentation.  Any additional relevant information the qualified professional finds appropriate. Rev. unusual or unexpected changes in clinical status. Refer to the “Reporting Units of Service” section in this manual for instructions on how to count minutes. the name and professional identification of the supervisor shall be included in the progress report.

Example: A beneficiary received occupational therapy (HCPCS “timed” code 97530. providers should not bill for services performed for fewer than eight minutes. Example: A beneficiary received a speech-language pathology evaluation represented by HCPCS “untimed” code 92506. the provider enters “1” in the field labeled units. then two units should be billed. units are reported based on the number of times the procedure is performed. and tests and measurements specify that the direct (one-on-one) time spent in patient contact is 15 minutes. Time intervals for one through eight units are as follows: Units 1 unit 2 units 3 units 4 units 5 units 6 units 7 units 8 units Number of Minutes 8 minutes to < 22 minutes 23 minutes to < 37 minutes 38 minutes to < 52 minutes 53 minutes to < 67 minutes 68 minutes to < 82 minutes 83 minutes to < 97 minutes 98 minutes to < 112 minutes 113 minutes to < 127 minutes > > > > > > > > Rev. providers bill a single 15-minute unit for treatment longer than or equal to eight minutes through and including 22 minutes. Regardless of the number of minutes spent providing this service. procedures. For any single timed CPT code in the same day measured in 15-minute units. The provider would then report four units. 01/2012 61 Reporting Units of Service . which is defined in 15-minute units) for a total of 60 minutes. only one unit of service is appropriately billed on the same day. For untimed codes. Several CPT codes used for therapy modalities. Providers report procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute-units of service. Counting Minutes for Timed Codes in 15-Minute Units When only one service is provided in a day. as described in the HCPCS code definition (often once per day). through and including 37 minutes.MEDICARE PART B Therapy Services REPORTING UNITS OF SERVICE Timed and Untimed Codes When reporting service units for HCPCS codes when the procedure is not defined by a specific time frame (“untimed” HCPCS). If the duration of a single modality or procedure in a day is longer than or equal to 23 minutes.

so each shall be billed for at least one unit. that service shall be billed for at least one unit. code 97110. the total number of timed minutes must be documented. If a provider has a consistent practice of billing fewer than 15 minutes for a unit. See the chart above. then bill one unit for the service performed for the most minutes. It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were performed for more than 15 minutes. Example 1: 24 minutes of neuromuscular re-education. The 47 minutes falls within the range for three units = 38 to 52 minutes. etc. If any 15-minute timed service that is performed for seven minutes or fewer than seven minutes on the same day as another 15-minute timed service that was also performed for seven minutes or fewer and the total time of the two is eight minutes or greater than eight minutes. these situations should be highlighted for review. The correct coding is two units of code 97112 and one unit of code 97110. The same logic is applied when three or more different services are provided for seven minutes or fewer than seven minutes. code 97112. When more than one service represented by 15-minute timed codes is performed in a single day. assigning more Rev. If a service represented by a 15-minute timed code is performed in a single day for at least 15 minutes. If the service is performed for at least 30 minutes.MEDICARE PART B Therapy Services The pattern remains the same for treatment times that exceed two hours. 23 minutes of therapeutic exercise. 01/2012 62 Reporting Units of Service . 47 total timed minutes. Appropriate billing for 47 minutes is only three timed units. Treatment notes should indicate that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the treatment note. This is correct because the total time is greater than the minimum time for one unit. These examples indicate how to count the appropriate number of units for the total therapy minutes provided. Each of the codes is performed for more than 15 minutes. However. that service shall be billed for at least two units. the total number of minutes of service (as noted on the chart above) determines the number of units billed. If more than one 15-minute timed CPT code is billed during a single calendar day. the total number of timed units that can be billed is constrained by the total treatment minutes for that day. The expectation (based on the work values for these codes) is that a provider’s direct patient contact time for each unit will average 15 minutes in length.

21 total timed minutes. 13 minutes of manual therapy. 01/2012 63 Reporting Units of Service . code 97116. 40 total timed minutes. code 97110. Appropriate billing is for one unit. 20 minutes of therapeutic exercise. 7 minutes of therapeutic exercise. Since the time for each service is the same. 7 minutes of manual therapy. code 97140. code 97035. 40 total timed minutes.MEDICARE PART B Therapy Services timed units to the service that took the most time. code 97112. 97110. 8 minutes of ultrasound. but the total allows three units. 97116 and 97140.. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (seven minutes) and bill the larger. 97110. Count the first 30 minutes of 97110 as two full units. code 97110. Bill one unit each of 97110. Each service was done at least 15 minutes and should be billed for at least one unit. Appropriate billing for 40 minutes is for three units. Example 4: 18 minutes of therapeutic exercise.e. Do not bill three units for either one of the codes. Section 220) shall select one appropriate CPT code (97112. You would still document the ultrasound in the treatment notes. 97140) to bill since each unit was performed for the same amount of time and only one unit is allowed. 100-02. The qualified professional (see definition in IOM Pub. Example 3: 33 minutes of therapeutic exercise. Example 2: 20 minutes of neuromuscular re-education. code 97110. Appropriate billing for 40 minutes is three units. which is 97140. 10 minutes of gait training. code 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i. 49 total timed minutes. Chapter 15. you may not bill four units for fewer than 53 minutes regardless of how many services were performed). Rev. Appropriate billing is for three units. Bill two units of 97110 and one unit of 97140. Bill the procedures you spent the most time providing. Example 5: 7 minutes of neuromuscular re-education. code 97112. 97140. choose either code for two units and bill the other for one unit. 7 minutes of manual therapy.

MEDICARE PART B
Therapy Services
Note: The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the eighth should be excluded from the total count. The total minutes of active treatment counted for all 15minute timed codes includes all direct treatment time for the timed codes. Total treatment minutes, including minutes spent providing services represented by untimed codes, are also documented. Specific Limits for HCPCS The Deficit Reduction Act of 2005, Section 5107, requires the implementation of clinically appropriate code edits to eliminate improper payments for outpatient therapy services. The following codes may be billed, when covered, only at or below the number of units indicated on the chart per treatment day. When higher numbers of units are billed than those indicated in the table below, the units on the claim line that exceed the limit shall be denied as medically unnecessary. Denied claims may be appealed and an Advance Beneficiary Notice (ABN) is appropriate to notify the beneficiary of liability. This chart does not include all of the codes identified as therapy codes; refer to the “Modifier” section for further detail on these and other therapy codes. For example, therapy codes called “always therapy” must always be accompanied by therapy modifiers identifying the type of therapy plan of care under which the service is provided. Use the chart in the following manner: The codes that are allowed one unit for “Allowed Units” in the chart below may be billed no more than once per provider, per discipline, per date of service, per patient. The codes allowed 0 units in the column for “Allowed Units,” may not be billed under a plan of care indicated by the discipline in that column. Some codes may be billed by one discipline (e.g., physical therapy) and not by others (e.g., occupational therapy or speech-language pathology). When physicians/Non-Physician Practitioners (NPPs) bill “always therapy” codes, they must follow the policies of the type of therapy they are providing, e.g., utilize a plan of care, bill with the appropriate therapy modifier (GP, GO, GN), bill the allowed units on the chart below for physical therapy, occupational therapy or speech-language pathology depending on the plan. A physician/NPP shall not bill an “always therapy” code unless the service is provided under a therapy plan of care. Therefore, “NA” stands for “Not Applicable” in the chart below. When a “sometimes therapy” code is billed by a physician/NPP, but as a medical service and not under a therapy plan of care, the therapy modifier shall not be used, but the number of units billed must not exceed the number of units indicated in the chart

Rev. 01/2012

64

Reporting Units of Service

MEDICARE PART B
Therapy Services
below per patient, per provider/supplier, per day. Code Description and Claim Line Outlier/Edit Details Physician/ Timed PT OT SLP NPP Not or Allowed Allowed Allowed Under Untimed Units Units Units Therapy POC Untimed 0 0 1 NA Untimed Timed Untimed Untimed Untimed Untimed Untimed Untimed Untimed Untimed Untimed Untimed Untimed Untimed 0 0 0 0 0 0 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 0 1 1 0 0 0 0 NA NA 1 1 1 1 1 1 1 1 NA NA NA NA

HCPCS

92506© Speech/hearing evaluation 92597© Oral speech device eval 92607© Ex for speech device rx, 1hr 92611© Motion fluoroscopy/swallow 92612© Endoscope swallow test (fees) 92614© Laryngoscopic sensory test 92616© Fees w/laryngeal sense test 95833© Limb muscle testing, manual 95834© Limb muscle testing, manual 96110© Developmental test, lim 96111© Developmental test, extend 97001© PT evaluation 97002© PT re-evaluation 97003© OT evaluation 97004© OT re-evaluation

Rev. 01/2012

65

Reporting Units of Service

MEDICARE PART B
Therapy Services

TrailBlazer’s Utilization Guidelines
TrailBlazer has a Local Coverage Determination Policy (LCD) in effect for therapy services and in that LCD TrailBlazer has established utilization guidelines for timebased codes. Effective with services rendered on or after May 17, 2010, the LCD provides authority for automated claim denial of claims for services in excess of the following:  Five (15 minutes each) timed PT services per patient per day.  Five (15 minutes each) timed OT services per patient per day.  Sixty (15 minutes each) PT services per patient per month.  Sixty (15 minutes each) OT services per patient per month. Providers of PT/OT services must be aware, however, that any service reported to Medicare, even when reported at a frequency within the following stated covered guidelines, may be denied if done so in association with medical review of the patient’s record that demonstrates no medical necessity for the services. Similarly, services in addition to the above limits may be payable when medical review of the patient’s record demonstrates medical necessity for additional services. Likewise, providers of PT/OT services must understand that although Medicare will allow the following units of service, each service must be medically reasonable and necessary for the specific patient and his condition. Additionally, Medicare expects that the patient’s medical record will clearly demonstrate that medical necessity. Further, Medicare does not expect that maximum allowable services will be routinely necessary, necessary for multiple-week periods, or necessary for the entirety of the patient’s course of treatment. Any federally established financial limitations on outpatient therapy services’ coverage and coding rules will apply. The “Therapy Services (PT, OT, and SLP)” LCD can be viewed at: http://www.trailblazerhealth.com/Tools/LCDs.aspx

Determining What Time Counts Toward 15-Minute Timed Codes – All Claims
Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted in determining the treatment service time. In other words, the time counted as “intra-service care” begins when the therapist or physician (or an assistant under the supervision of a physician or therapist) is directly working with the patient to deliver treatment services. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.
Rev. 01/2012 66 Reporting Units of Service

Rev. In addition. the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time. each 15 minutes the patient is being treated can count as only one unit of code 97116. or even two therapists to manage in the parallel bars. The time the patient spends not being treated because of the need for toileting or resting should not be billed. For example.MEDICARE PART B Therapy Services The time counted is the time the patient is treated. if gait training in a patient with a recent stroke requires both a therapist and an assistant. 01/2012 67 Reporting Units of Service .

2002. Rev. In 1999. The Tax Relief and Health Care Act of 2006 extended the cap exceptions process through calendar year 2007. Section 421 of the Medicare. Moratoria and Exceptions for Therapy Claims Since the creation of therapy caps. Physical Therapists (PTs). Occupational Therapists (OTs) and Speech-Language Pathologists (SLPs). through December 7. Congress re-enacted a moratorium on financial limitations on outpatient therapy services on December 8. as well as physicians and certain Non-Physician Practitioners (NPPs). The Medicare. Caps were implemented again on January 1. that extended through December 31. The limit is based on incurred expenses and includes applicable deductible and coinsurance. 2003. 2002.500 applied to all outpatient physical therapy services (including speech-language pathology services). could render a therapy service. and policies were modified to allow exceptions as directed by the Deficit Reduction Act of 2005 only for calendar year 2006. Future exceptions: The cap exception for therapy services billed by outpatient hospitals was part of the original legislation and applies as long as caps are in effect. Implementation was delayed until September 1. A separate limit applied to all occupational therapy services. extended the moratorium on application of the financial limitation to claims for outpatient rehabilitation services with dates of service January 1. 2008. 2006. Congress has enacted several moratoria and an exceptions process. The BBA provided that the limits be indexed by the Medicare Economic Index (MEI) each year beginning in 2002.MEDICARE PART B Therapy Services THE FINANCIAL LIMITATION (THERAPY CAP) Overview Section 4541 of the Balanced Budget Act (BBA) required application of a financial limitation to all outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). which has been extended periodically. 2003. 01/2012 68 The Financial Limitation (Therapy Cap) . Medicaid and SCHIP Extension Act of 2007 extended the cap exceptions process for services furnished through June 30. 2000. Therapy caps were in effect for services rendered September 1. 2005. The limitation is based on therapy services the Medicare beneficiary receives. not the type of practitioner who provides the service. there was not a moratorium on therapy caps. 2003. through December 31. through December 31. an annual per beneficiary limit of $1. Medicaid and State Children’s Health Insurance Program (SCHIP) Benefits Improvement and Protection Act (BIPA) of 2000. 2002. In 2003. 2003. the moratorium was for a three-year period and applied to outpatient rehabilitation claims with dates of service January 1. Therefore.

The therapy caps are determined on a calendar year basis. the limit on incurred expenses is $1.880. the limit is $1. Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA) Extension of Exceptions Process for Medicare Therapy Caps Section 304 of the TPTCCA extends the exceptions process for outpatient therapy caps.870 for 2011 and $1. when an exception is appropriate.880. One provision of this legislation extends the effective date of the exceptions process to the therapy caps to December 31. For physical therapy and speech language pathology services combined. For occupational therapy services. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached and also apply for services above the cap where the KX modifier is used. 2006. 2010. 2010.880 for 2012. The annual limit on the allowed amount for outpatient physical therapy and speechlanguage pathology combined is $1. The Medicare Improvements for Patients and Providers Act of 2008 was enacted on July 15. 2009.MEDICARE PART B Therapy Services Exceptions to caps based on the medical necessity of the service are in effect only when Congress legislates the exceptions. retroactive to January 1. Section 3103 of the Patient Protection and Affordable Care Act continues the exceptions process. for services furnished on or after January 1. Therapy Cap Exception Process Extended Under the Temporary Extension Act of 2010 – The Temporary Extension Act of 2010.870 for 2011 and $1. extends the therapy cap exceptions process through March 31. 2010. when an exception is appropriate. as it did for 2007. 2010. 2010. 2012. 2012. through December 31. 2012. 2010. for services furnished January 1. 2012. the limit for occupational therapy is $1. Outpatient therapy service providers may continue to submit claims with the KX modifier. effective for dates of service on or after January 1. Outpatient therapy service providers may be submit claims with the KX modifier. and continues through December 31. Rev. through March 31. through February 29. 2010. References to the exceptions process in subsection C of this section apply only when the exceptions are in effect. 2008. 01/2012 69 The Financial Limitation (Therapy Cap) . Outpatient Therapy Caps The financial limitations on outpatient therapy services begins on or after on January 1.880 for 2012. enacted on March 2. so all patients begin a new cap year on January 1.

These amounts will change each calendar year. Rev. These excluded hospital services are reported on types of bill 12X or 13X or 85X. With the exceptions of the use of the KX modifier. Exceptions to Therapy Caps The Deficit Reduction Act of 2005 directed CMS to develop exceptions to therapy caps for calendar year 2006. and those exceptions have been extended several times by subsequent legislations. the guidance in this section concerning medical necessity applies as well to services provided before caps are reached. the Exception Processes fell into two categories: automatic process exceptions and manual process exceptions. beneficiaries pay the coinsurance (20 percent) and any deductible that may apply. Medicare will pay the remaining 80 percent of the limit after the deductible is met. there is no manual process for exceptions. Rather. 2007.MEDICARE PART B Therapy Services Therapy providers may continue to submit therapy claims with KX modifiers for services during this period. All services that require exceptions to caps shall be processed using the automatic process. As with any Medicare payment. Beginning January 1. atypical use of the automatic exception process may invite contractor scrutiny. Particular care should be taken to document improvement and avoid billing for services that do not meet the requirements for skilled services or for services which are maintenance rather than rehabilitative treatment. TrailBlazer applies the financial limitations to the allowed amount for therapy services for each beneficiary. The KX modifier should be used by providers when they know the therapy cap has already been met. 01/2012 70 The Financial Limitation (Therapy Cap) . In 2006. The following policies concerning exceptions to caps due to medical necessity apply only when the exceptions process is in effect. The beneficiary may qualify for use of the cap exceptions at any time during the episode when documented medically necessary services exceed caps. Use of the automatic process for exception does not exempt services from manual or other medical review processes. Limits apply to outpatient Part B therapy services from all settings except outpatient hospital (place of service code 22 on contractor claims) and hospital emergency room (place of service code 23 on contractor claims). Medicare shall apply these financial limitations in order. according to the dates when the claims were received. All covered and medically necessary services qualify for exceptions to caps. All requests for exception are in the form of a KX modifier added to claim lines.

for example. e. Automatic Process Exceptions The term “automatic process exceptions” indicates the claims processing for the exception is automatic. frequency and duration. not that the exception is automatic. to achieve his prior functional status or maximum expected functional status within a reasonable amount of time. No special documentation is submitted to TrailBlazer for automatic process exceptions. the following evaluation procedures may be appropriate: The following is a list of evaluation codes: 92506. i. refer to the “General Documentation” section in this manual. Rev. Exceptions for Evaluation Services Evaluation CMS will except therapy evaluations from caps after the therapy caps are reached when evaluation is necessary. complexities and severity  The services provided including their type. Documentation justifying the services shall be submitted in response to any Additional Documentation Request (ADR) for claims that are selected for medical review. clinicians may include.g. The clinician’s opinion is not binding on the Medicare contractor who makes the final determination concerning whether the claim is payable.e. 92607. to determine if the current status of the beneficiary requires therapy services. clinicians shall consider. For example.MEDICARE PART B Therapy Services The KX modifier is added to claim lines to indicate the clinician attests that services are medically necessary and justification is documented in the medical record.. For documentation requirements. In addition. The clinician is responsible for consulting the Medicare manuals and professional literature to determine if the beneficiary may qualify for the automatic process exception because documentation justifies medically necessary services above the caps. If medical records are requested for review.  The interaction of current active conditions and complexities that directly and significantly influence the treatment such that it causes services to exceed caps. 92610. 92597. In making a decision about whether to utilize the automatic process exception. 01/2012 71 The Financial Limitation (Therapy Cap) . at their discretion. 92608. therapy beyond the amount payable under the therapy cap. whether services are appropriate to:  The patient’s condition including the diagnosis. 92611. the following should be considered before using the automatic exception process.. a summary that specifically addresses the justification for therapy cap exceptions. An exception may be made when the patient’s condition is justified by documentation indicating that the beneficiary requires continued skilled therapy.

frequency and intensity of services are appropriate to an individual. 01/2012 72 The Financial Limitation (Therapy Cap) . medically necessary service. per episode. 97001. Guidelines for utilization of therapy services may be found in Medicare manuals. 97003 and 97004. For example. especially when they exceed caps.gov/TherapyServices/ (Studies and Reports) for more recent utilization reports. 96105. when billing for therapy services. Exceptions for Medically Necessary Services Clinicians may utilize the automatic process for exception for any diagnosis or condition for which they can justify services exceeding the cap. the ICD-9CM code that best relates to the reason for the treatment shall be on the claim. Contractors shall not limit medically necessary services that are justified by scientific research applicable to the beneficiary. For example. see the CSC – Therapy Cap Reports and CSC – Therapy Edits Tables 4-14-2008 at http://www. When submitting claims for necessary evaluation services that exceed the caps. The modifier alerts TrailBlazer to override a denial for that service due to the cap. As always.cms.MEDICARE PART B Therapy Services 92612. unless there is a compelling reason to report another diagnosis code. Clinicians and contractors should utilize available evidence related to the patient’s condition to justify provision of medically necessary services to individual beneficiaries. 97002. Medicare contractors’ Local Coverage Determinations (LCDs) and professional guidelines issued by associations and states. Neither contractors nor clinicians shall utilize professional literature and scientific reports to justify payment for continued services after an individual’s goals have been met earlier than is typical. 92614. the patient must require skilled treatment for a covered. 92616. Conversely. frequency and duration for the patient’s condition and the service must be documented appropriately. providers and suppliers are instructed to attach the KX modifier to the evaluation procedures listed above to identify them as an excepted therapy procedure. For example. professional literature and scientific reports shall not be used as justification to deny payment to patients whose needs are greater than is typical or when the patient’s condition is not represented by the literature. Bill the most relevant diagnosis. Regardless of the diagnosis or condition. the services must be appropriate in type. Documentation shall provide the complaint or condition that indicates why the evaluation was necessary. Documentation shall describe any complexities that directly and substantially impact the patient’s treatment. when a Rev. per condition or per discipline. the patient must also meet other requirements for coverage. either per service. Professional literature and guidelines from professional associations also provide a basis on which to estimate whether the type. Other Services There are a number of sources that suggest the amount of certain services that may be typical.

Other variables (such as the availability of a caregiver at home) that affect appropriate treatment shall also be considered. clinical guidelines from professional sources and/or clinical/common sense. Routine use of the KX modifier for all patients with these conditions will likely show up on data analysis as aberrant and invite inquiry. Be sure that documentation is sufficiently detailed to support the use of the modifier. When a claim includes several types of services. Where it is possible in accordance with state and local laws and the contractors’ LCDs. be on the claim in another position. Use the KX modifier only in cases where the condition of the individual patient is such that services are appropriately provided in an episode that exceeds the cap. it may not be possible to use the most relevant therapy diagnosis code in the primary position. Factors that influence the need for treatment should be supportable by published research.MEDICARE PART B Therapy Services patient with diabetes is being treated with therapy for gait training due to amputation. avoid using vague or general diagnoses. Residents of skilled nursing facilities prevented by consolidated billing from accessing hospital services. debilitated patients for whom transportation to the hospital is a physical hardship or lack of therapy services at hospitals in the beneficiary’s county may or may not qualify as justification for continued Rev. Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. the preferred diagnosis is abnormality of gait (which characterizes the treatment). if possible. 01/2012 73 The Financial Limitation (Therapy Cap) . Refer to the documentation sections of this manual for information related to documentation of the evaluation and medical necessity for some factors that complicate treatment. It is very important to recognize that most of the conditions would not ordinarily result in services exceeding the cap. The condition or complexity that caused treatment to exceed caps must be related to the therapy goals and must either be the condition that is being treated or a complexity that directly and significantly impacts the rate of recovery of the condition being treated such that it is appropriate to exceed the caps. Note that the patient’s lack of access to outpatient hospital therapy services alone does not justify excepted services. Documentation for an exception should indicate how the complexity (or combination of complexities) directly and significantly affects treatment for a therapy condition. In that case. or when the physician/NPP must supply the diagnosis. Additional Considerations for Exceptions In justifying exceptions for therapy caps. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance where there is no more relevant code. clinicians and contractors should not only consider the medical diagnoses and medical complications that might directly and significantly influence the amount of treatment required. the relevant diagnosis code should.

 If this attestation is determined to be inaccurate. Contractors may review claims with KX modifiers to determine whether the services are medically necessary or for other reasons. GO or GP therapy modifiers are currently required to be appended to therapy services. Appeals If a beneficiary whose excepted services do not meet the Medicare criteria for medical necessity elects to receive such services and a claim is submitted for such services. the GN. But. refer to this link: http://www. it is denied as a benefit category denial. Rev. o Are reasonable and necessary services that require the skills of a therapist. the provider is attesting that the services billed: o Qualified for an exception using the automatic process exception. o Are justified by appropriate documentation in the medical record. the resulting determination would be subject to the administrative appeals process. Note: For a list of codes that are subject to the therapy tracking CAP. are not medically necessary services. the provider shall add a KX modifier to the therapy HCPCS code subject to the cap limits. KX Modifier for Therapy Cap Exceptions When exceptions are in effect and when the beneficiary qualifies for a therapy cap exception. Services without a Medicare benefit may be billed to Medicare with a GY modifier for the purpose of obtaining a denial that can be used with other insurers. GP and GO modifiers shall continue to be used.asp#TopOfPage. In addition to the KX modifier.MEDICARE PART B Therapy Services services above the caps. 01/2012 74 The Financial Limitation (Therapy Cap) . when a service provided beyond the cap (outside the benefit) is determined to be not medically necessary. but their location does not. The patient’s condition and complexities might justify extended services. Services that exceed therapy caps but do not meet Medicare criteria for medically necessary services are not payable even when clinicians recommend and furnish these services.cms. it is covered and payable. the provider/supplier is subject to sanctions resulting from providing inaccurate information on a claim. this applies to services that.  The GN. (For more information refer to the “Modifiers” section of this manual. according to TrailBlazer’s LCD.) By attaching the KX modifier. The KX modifier shall not be added to any line of service that is not a medically necessary service. Appeals Related to Disapproval of Cap Exceptions When a service beyond the cap is determined to be medically necessary.gov/TherapyServices/05_Annual_Therapy_Update.

com/Publications/PDF Form/PartBRedeterminationRequestForm. Claim Issue The entire claim denied due to the cap. 01/2012 75 The Financial Limitation (Therapy Cap) . Claim Issue One line item allowed incorrectly due to the cap limitation. 2010.com/Publications/Training Manual/Appeals.MEDICARE PART B Therapy Services Claims Submitted Without the KX Modifier The following issues may be referenced when correcting services rendered prior to March 31. Example: Code 97110 allowed $5 and it should have allowed $10. A redetermination request is not needed. GO. The patient’s medical record should reflect the automatic exception. GP) and the KX modifier. refer to the Appeals manual located at: http://www. (If the entire claim is refiled.pdf Rev. Solution Refile only the denied services with the appropriate PT/OT modifier (GN.trailblazerhealth. Documentation should not be submitted with the claim. Claim Issue Denied and allowed services due to the cap on the same claim.pdf For additional information about how to request a redetermination. GO. The patient meets the automatic exception. Solution Refile the claim with the appropriate PT/OT modifier (GN. Documentation should not be submitted with the claim. GP) and the KX modifier. The patient meets the automatic exception.trailblazerhealth. The patient’s medical record should reflect the automatic exception. the allowed services will deny as duplicates.) A redetermination request is not needed. The patient meets the automatic exception. Solution A redetermination will need to be requested by submitting a Part B Redetermination Request Form located at: http://www. The therapy cap limitation was met on this line. and the patient meets an automatic exception.

(Refer to the “Modifiers” section in this manual. regardless of the impact of the condition on the need for services above the cap.  Providers and suppliers shall continue to attach National Correct Coding Initiative (NCCI) HCPCS modifiers under current instructions.MEDICARE PART B Therapy Services Progressive Corrective Action (PCA) and Medical Review Progressive Corrective Action (PCA) and medical review have a role in the therapy prior authorization exception process. and there shall be no evidence of abusive or inappropriate use of the process or the services by the provider/supplier. Although the services may meet the criteria for exception from the cap due to conditions or complexities. The routine use of the KX modifier on every claim for a patient that has an excepted condition or complexity. Services provided in a capped setting after the limitation has been reached are not Medicare benefits and are not governed by Medicare policies. Provider Notification for Beneficiaries Exceeding Therapy Limits When the provider/supplier knows that the limit has been reached. and exceptions are either not appropriate or not available. they are still subject to review to determine that the services are otherwise covered and appropriately provided. TrailBlazer will not count the expenditure against the applicable PT/SLP or OT cap amount. An example of inappropriate use of the process is the routine application for exceptions after the cap has been exceeded.) If a claim is submitted without KX modifiers and the cap is exceeded. the provider/supplier is subject to sanctions resulting from providing inaccurate information on a claim. contractors may reopen and/or adjust the claim if it is brought to their attention. the services may be billed at the rate the provider/supplier determines. the documentation must accurately represent the facts. In cases where the KX would have been appropriate. fraud or abuse. Services deemed medically necessary are still subject to review related to misrepresentation. 01/2012 76 The Financial Limitation (Therapy Cap) .If the beneficiary chooses to continue treatment at a setting other than the outpatient hospital where medically necessary services may be covered.  When the KX modifier is attached to a therapy HCPCS. The exception is granted (either automatically or by manual exception) on the clinician’s assertion that there is documentation in the record justifying that the services meet the criteria for reasonable and necessary services. The providers/suppliers should inform the beneficiary of the therapy financial limitations and his option of receiving further covered services from an outpatient hospital (unless consolidated billing rules prevent the use of the outpatient hospital setting). If a beneficiary elects to receive services that exceed the cap limitation and a claim is Rev. If this attestation is determined to be inaccurate. those services will be denied. For example. further billing should not occur. is inappropriate.

MEDICARE PART B Therapy Services submitted for such services. It is the provider’s responsibility to present each beneficiary with accurate information about the therapy limits. appropriate care above the limits can be obtained at a hospital outpatient therapy department. and that. the resulting determination is subject to the appeals process. unless this outpatient care is furnished directly or under arrangements by a hospital. Patients who are residents in a Medicare-certified part of a Skilled Nursing Facility (SNF) may not utilize outpatient hospital services for therapy services over the financial limits because consolidated billing rules require all services be billed by the SNF. Rev. Providers/suppliers should inform beneficiaries that beneficiaries are responsible for 100 percent of the costs of therapy services above each respective therapy limit. However. when therapy cap exceptions apply. 01/2012 77 The Financial Limitation (Therapy Cap) . where necessary. an SNF resident may qualify for exceptions that allow billing within the consolidated billing rules.

At the time the clinician determines that skilled services are not necessary. The ABN is also used before the cap is exceeded when notice about non-covered services is mandatory. providers must adhere to the form requirements. Medicare will not pay for physical therapy and speech-language pathology services over (add the dollar amount of the cap) in (add the year or the dates of service to which it applies) unless the beneficiary qualifies for a cap exception. When the ABN is used as a mandatory notice. providers could use the Notice of Exclusion from Medicare Benefits (NEMB Form No. 01/2012 78 The Financial Limitation (Therapy Cap) . 2009. providers may now use a form of their own design. In its place. whenever the treating clinician determines that the services being provided are no longer expected to be covered because they do not satisfy Medicare’s medical necessity requirements. the clinical goals have been met. Advance Beneficiary Notice of Noncoverage (ABN) An Advance Beneficiary Notice of Noncoverage (ABN) is required to be given to a beneficiary whenever the treating clinician determines that the services being provided Rev. beneficiaries should be informed that Medicare most likely will not provide additional coverage. The ABN informs the beneficiary of his potential financial obligation to the provider and provides guidance regarding appeal rights. voluntary notice via a provider’s own form or the ABN is appropriate. The provider should include the beneficiary’s name on the form and the reason Medicare may not pay in the space provided within the form’s table. If the beneficiary requests further services. For example. even when services are excepted from the cap. After the cap is exceeded. Providers are to supply this same information for occupational therapy services over the limit for the same time period. or that there is no longer potential for the rehabilitation of health and/or function in a reasonable time. an ABN must be issued before the beneficiary receives that service. CMS 20007) to inform a beneficiary of financial liability for therapy above the cap when no exception applied.MEDICARE PART B Therapy Services Prior to March 1. When using the ABN form as a voluntary notice. A cost estimate for the services may be included but is not required. the form requirements specified for its mandatory use do not apply. the NEMB form has been discontinued. Form CMS-R-131) may be used as a voluntary notice. if appropriate. or the Advance Beneficiary Notice of Noncoverage (ABN. however. Insertion of the following reason is suggested: Services do not qualify for exception to therapy caps. and the ABN should be issued prior to delivering any services. The beneficiary should not be asked to choose an option or sign the form. the beneficiary should be informed.

the ABN is appropriate. Example: If services are provided over the cap for an excepted condition. Rev. For complete ABN instructions.pdf After the cap is exceeded. The ABN applies to services that are provided before the cap is exceeded. Use the ABN form for this purpose if the services are within the cap or for services after the cap is exceeded. or that there is no longer potential for the rehabilitation of health and/or function in a reasonable time.cms. The ABN informs the beneficiary of his potential financial obligation to the provider and provides guidance regarding appeal rights. when the therapist determines the services no longer meet the criteria for reasonable and necessary services.MEDICARE PART B Therapy Services are no longer expected to be covered because they do not satisfy Medicare’s medical necessity requirements. 01/2012 79 The Financial Limitation (Therapy Cap) . refer to the CMS Web Resources Advance Beneficiary Notice of Noncoverage (ABN) Booklet at: http://www.gov/MLNProducts/downloads/ABN_Booklet_ICN006266. the beneficiary should be informed. an ABN may be provided to the patient. If the beneficiary requests further services. regardless of whether the services were excepted from the cap. inform the beneficiary that Medicare will not likely provide additional coverage. At the time the clinician determines that skilled services are not necessary. the clinical goals have been met.

Therapy modifiers should never be used with codes that are not on the list of applicable therapy codes.pdf Evaluation and Management (E/M) 25 Modifier Significant. the financial limitation is based on the presence of therapy modifiers. assist in determining appropriate coverage or otherwise identify the detail on the claim. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. The use of modifiers becomes more important every day when reporting services to ensure appropriate reimbursement from Medicare. Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed. separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed.gov/MLNProducts/downloads/ABN_Booklet_ICN006266. As such.MEDICARE PART B Therapy Services MODIFIERS Introduction Modifiers are used to modify payment of a procedure code. When limitations are in effect. the patient’s condition required a significant. Advance Beneficiary Notice of Noncoverage (ABN) For complete ABN instructions.cms. different diagnoses are not required for reporting of the E/M services on the same date. Providers/suppliers must continue to report one of these modifiers for any therapy code on the list of applicable therapy codes. These codes should be entered in Item 24d of the CMS1500 claim form for paper billers or the electronic equivalence. refer to the CMS Web Resources Advance Beneficiary Notice of Noncoverage (ABN) Booklet at: http://www. 01/2012 80 Modifiers . The modifiers do not allow a provider to deliver services they are not qualified and recognized by Medicare to perform. This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service. except as noted. Therapy Modifiers Modifiers are used to identify therapy services whether financial limitations are in effect. Rev. The claim must include one of the following modifiers to distinguish the discipline of the plan of care under which the service is delivered.

When in effect.gov/TherapyServices/05_Annual_Therapy_Update. Skilled Nursing Facilities (SNFs) and any others billing for physical therapy. Therapy modifiers are:  GP for physical therapy.MEDICARE PART B Therapy Services Outpatient Therapy GN Services delivered under an outpatient speech-language pathology plan of care. speech-language pathology or occupational therapy services as noted on the applicable code list. occupational therapy and speech-language pathology services. Occupational Therapists in Private Practice (OTPPs).asp as therapy services. Physical Therapists in Private Practice (PTPPs).cms. Modifiers refer only to services provided under plans of care for physical therapy. 01/2012 81 Modifiers . 2009). Occupational Therapist (OT) or Speech-Language Pathologist (SLP). occupational therapy and speechlanguage pathology services. CMS identifies the codes listed at: http://www. they are considered therapy services and must meet the other conditions Rev. GO Service delivered under an outpatient occupational therapy plan of care. Comprehensive Outpatient Rehabilitation Facilities (CORFs).  GO for occupational therapy. This is applicable to all claims from physicians. Non-Physician Practitioners (NPPs). These HCPCS codes describe services for the improvement of respiratory function and may represent either “incident to” services or respiratory therapy services that may be appropriately billed in the CORF setting. Example: Outpatient non-rehabilitation HCPCS codes G0237. Regardless of financial limitation. Therapist means only a Physical Therapist (PT). GP Service delivered under an outpatient physical therapy plan of care.cms. hospitals. G0238 and G0239 should be billed without therapy modifiers. Therapy services include only physical therapy. Speech-Language Pathologists in Private Practice (SLPPPs) (for services rendered on or after July 1.  GN for speech-language pathology. Additional HCPCS Codes Some HCPCS/CPT codes that are not on the list of therapy services should not be billed with a modifier.gov/TherapyServices/. any financial limitation will also apply to services represented unless otherwise noted on the therapy page on the CMS Web site at: http://www. providers of Outpatient Physical Therapy (OPT) and speechlanguage pathology services. When the services described by these “G” codes are provided by PTs or OTs treating respiratory conditions.

National Correct Coding Initiative (NCCI) CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and eliminate improper coding. Another example of codes that are not on the list of therapy services and should not be billed with a therapy modifier includes the following HCPCS codes: 95860. This set of edits is based on anatomical considerations and addresses approximately 2. but were deleted because it was determined they represented services most often performed outside a therapy plan of care. when these services are provided by therapists or as an integral part of a therapy plan of care.. However. 95864. 95904 and 95934. NCCI edits are developed based on coding conventions defined in the American Medical Association’s CPT book. MEDICALLY UNLIKELY EDITS (MUEs) To lower the Medicare fee-for-service paid claims error rate. 95900. The National Correct Coding Initiative (NCCI) contractor develops and maintains MUEs. input from specialty societies and analysis of current coding practice. imply applicability to provider settings and does not assure coverage of these services. The PT or OT would use the appropriate HCPCS/CPT code(s) in the 97000–97799 series and the corresponding therapy modifier. the CPT code must be accompanied by the appropriate therapy modifier. 95870. other MUE values are confidential and are not published for public viewing. One example of non-listed codes where a therapy modifier is indicated regards the provision of services described in the CPT code series 29000–29590 for the application of casts and strapping. It is not intended to be an exhaustive list of covered services. Other codes not on the therapy code list and not paid under another fee schedule are appropriately billed with therapy modifiers when the services are furnished by therapists or provided under a therapy plan of care and where the services are covered and appropriately delivered (e. the therapist is qualified to provide the service). 95863.800 codes. CMS established units of service edits referred to as Medically Unlikely Edits (MUEs).MEDICARE PART B Therapy Services for physical and occupational therapy. Some of these codes previously appeared on the therapy code list. Although CMS publishes most MUE values.g. Refer to the How to Use the National Correct Coding Initiative (NCCI) Tools manual for additional information: Rev. GP or GO. 95861. must be used. Note: The previous lists of HCPCS/CPT codes are intended to facilitate the contractor’s ability to pay claims under the Medicare Physician Fee Schedule. 95867. 95903. 01/2012 82 Modifiers . 95869. current standards of medical and surgical coding practice. These services represent diagnostic services – not therapy services – and must be appropriately billed without therapy modifiers.

Miscellaneous GY LT RT Item or service statutorily excluded or does not meet the definition of any Medicare benefit Left side Right side The medical record must reflect that the modifier is being used appropriately to describe separate services. manual lymphatic drainage. each 15 minutes. The two codes cannot be reported together if performed during the same 15-minute time interval. manual traction). Policy: Mutually exclusive procedures.pdf Proper Use of the 59 Modifier Example Column 1 Code/Column 2 Code 97140/97530  CPT Code 97140 – Manual therapy techniques (e.g.MEDICARE PART B Therapy Services https://www.  CPT Code 97530 – Therapeutic activities. mobilization/manipulation. one or more regions. direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance). The documentation should be maintained in the patient’s medical record and must be made available to Medicare upon request. Modifier 59 is only appropriate if the two procedures are performed in distinctly different 15-minute intervals.cms.. Rev.gov/MLNProducts/downloads/How-To-Use-NCCI-Tools. 01/2012 83 Modifiers . each 15 minutes.

by patient factors such as age. the practitioner will support the need for continued care with documentation that clearly outlines the factors that affect the rate of recovery and reinforces the anticipation that further functional gain is expected. whether the duration and intensity of rehabilitative services rendered is limited or extensive. the dynamic component of therapy. mobilization and patient education should predominate. Rev. an Non-Physician Practitioner (NPP) and/or therapist supports utilization of the intervention and there is documentation of objective physical and functional limitations (signs and symptoms). may be represented by diagnoses (refer to the “Financial Limitation” section in this manual). Though passive modalities may also predominate in the earlier phases of rehabilitation when the patient’s ability to participate in therapeutic exercise is restricted. swelling and other posttreatment syndromes. or the patient’s maximum rehabilitation potential have been realized.. Medicare expects the patient’s medical record to clearly demonstrate medical reasonableness and necessity for all therapy services. therapy is not reasonable and necessary and should not be reported to Medicare as a payable service. e. education and therapeutic exercise. 01/2012 84 Indications and Limitations of Coverage and/or Medical Necessity . In all cases. severity. Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care. or by the patient’s social circumstances such as the support of a significant other or the availability of transportation to therapy. recovery time and the ability to be educated and allows for a recertification for additional therapy as long as adequate medical documentation by the supervising physician or therapist is recorded in the medical record and the patient continues to demonstrate progress. The goal of rehabilitative medicine is discernible.g. Passive modalities should be used in the “warm-up” phase of the patient encounter as preparation for or as an adjunct to therapeutic procedures. General Physical Medicine and Rehabilitation (PM&R) Guidelines Intervention with Physical Medicine and Rehabilitation (PM&R) modalities and procedures is indicated when an assessment by a physician. If an individual’s expected rehabilitation potential is insignificant.MEDICARE PART B Therapy Services INDICATIONS AND LIMITATIONS OF COVERAGE AND/OR MEDICAL NECESSITY The cornerstones of rehabilitative therapy are mobilization. Medicare expects the patient’s record to clearly reflect medical necessity for passive modalities. Complicating factors that may influence treatment. In more refractory cases. both active and passive. frequency and/or duration of treatment. especially those that exceed 25 percent of the cumulative service hours of rehabilitative therapy provided for any beneficiary under a plan of care. To that end. functional progress toward the restoration or maximization of impaired neuromuscular and musculoskeletal function. multiple conditions and motivation. Further. including maximization of safety and independence. and in the “cool-down” phase for reduction of pain. they may influence the type. The contractor recognizes variability in strength. acuity.

long-term treatment goals and type. DO. but are not required to be licensed. OT. Medicare does not cover therapy services that do not require the skill of a trained and licensed practitioner to perform even when one of the persons in the list above performs them. Qualified personnel have met the educational and degree requirements of a licensed therapy professional (PT. duration and frequency of therapy services. o Medical Doctors (MDs) and Doctors of Osteopathy (DOs). o “Qualified” personnel when directly supervised by a physician (MD.MEDICARE PART B Therapy Services and the written plan of care incorporates those treatment elements that are expected to result in improvement of these limitations in a reasonable and generally predictable period of time. 01/2012 85 Indications and Limitations of Coverage and/or Medical Necessity . o Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency. OTs and SLPs. including Advanced Nurse Practitioners (ANPs).  A therapist may not significantly alter a plan of care established or certified by the physician or NPP without their documented written or verbal approval.  The plan must be periodically reviewed by the physician or NPP. o Licensed physical therapy assistants when supervised directly by a licensed PT. DPM) or qualified NPP and when all conditions of billing services “incident to” a physician have been met. must be established by the physician. o Qualified NPPs. New or significantly modified plans of care must be certified within 30 calendar days Rev. the services are not covered and must not be reported for Medicare payment. consisting of diagnoses. NPP or the therapist providing the services before the services are begun. Physician Assistants (PAs) or Clinical Nurse Specialists (CNSs) when performing services within their licenses’ scope of practice and their training and competency (ANP.  The plan must be certified and recertified periodically (refer to the “General Documentation” section in this manual for details) by the physician or NPP.  A written plan of care.  PM&R services must be furnished on an outpatient basis and provided while the patient is or was under the care of a physician or NPP. OD. Please note that unless these therapy services are performed by a “qualified” person. SLP). PA. amount.  Medicare covers therapy services that require the skill of a trained and licensed practitioner to perform or supervise. CNS). o Licensed occupational therapy assistants when supervised directly by a licensed OT.  Medicare covers therapy services personally performed only by one of the following: o Licensed therapy professionals: licensed PTs.

PM&R services in patients’ homes. it is usually not medically necessary to have more than one treatment session per discipline. qualified professionals’ offices. Additional time is sometimes required for more complex and/or slow-to-respond patients. o Range of motion and passive exercises that are not related to restoration of a specific loss of function. It is not medically necessary for a qualified professional to perform or supervise maintenance programs that do not require the professional skills of a qualified professional. frequency and duration of services must be medically necessary for the patient’s condition under accepted medical.e. unless delayed certification criteria are met. and assisted walking such as that provided in support for feeble or unstable patients. There must be an expectation that the condition or level of function will improve within a reasonable (and generally predictable) time or the services must be necessary to establish a safe and effective maintenance regimen required in connection with a specific disease.MEDICARE PART B Therapy Services after the initial treatment under that plan.or caregiver-directed. The type. but are useful in maintaining range of motion in paralyzed extremities. However. 01/2012 . general exercises to promote overall fitness and flexibility). For purposes of this 86 Indications and Limitations of Coverage and/or Medical Necessity        Rev. Recertifications must be obtained within the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan. Treatment times per session may vary based upon the patient’s medical initial therapy needs and progress to date toward established goals. will not exceed of 45–60 minutes. o Maintenance therapies after the patient has achieved therapeutic goals or for patients who show no further meaningful progress and should become patient. o Repetitive exercises to maintain gait or maintain strength and endurance. Outpatient Rehabilitation Facilities (ORFs) and Comprehensive Outpatient Rehabilitation Facilities (CORFs) are covered when reasonable and medically necessary for the treatment of the patient’s condition (signs and symptoms). Treatment times per session typically. whichever is less. For all PM&R modalities and therapeutic procedures on a given day. PT and OT may be covered if separate and distinct goals are documented in the treatment plans. These situations include: o Services related to activities for the general good and welfare of patients (i. it must be followed by a signature within 14 days to be timely. documentation of the exceptional circumstances must be maintained in the patient’s medical record and available upon request. outpatient hospital clinics.. If certification is obtained verbally. physical therapy and occupational therapy practice standards and relate directly to a written treatment plan. Skilled Nursing Facilities (SNFs). Services provided concurrently by a physician.

01/2012 87 Indications and Limitations of Coverage and/or Medical Necessity . The medical records indicate the following:  US – R shoulder x 10 minutes. generally administered and supervised by family or caregivers. If a maintenance program is not established until after the therapy program has been completed (and the skills of a therapist are not necessary). The proper coding is 97035 x QB 2. “service” is defined as each 15-minute billing increment. Instructing the patient. development of a maintenance program is not considered reasonable and necessary for the patient’s condition.  US – L shoulder x 10 minutes. However. Rev. For additional information. For codes that are defined as per 15 minutes or each 15 minutes. a “service” ID is defined as a 15-minute billing increment of a specific therapy CPT code. Example Qualified professional ABC123XYZ orders ultrasound for the right and left shoulder areas and lower back. Maintenance Therapy Maintenance therapy after therapeutic goals and/or rehabilitative potentials are reached is medically reasonable and necessary but is not covered. Note: The actual number of minutes involved is 30. refer to the “Reporting Units of Service” section of this manual. Report these codes based on the actual amount of time spent on a cumulative basis for the specified modality or procedure. Periodic evaluations of the patient’s condition and response to treatment may be covered when medically necessary if the judgment and skills of a qualified professional are required. which equals a quantity of two. Infrequent re-evaluations required to assess the patient’s condition and adjust the program. Medicare would not expect to see the qualified professional billing per treatment site.  US – Lower back x 10 minutes. Examples include:    Design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease. a qualified professional may develop a maintenance program for the patient to pursue outside of a therapy program and plan of care. For the purposes of this policy.MEDICARE PART B Therapy Services  policy. family member(s) or caregiver(s) in carrying out the maintenance program.

01/2012 .MEDICARE PART B Therapy Services Note: Bill these services (e. Utilization Guidelines Allowed units outlined in the table below may be billed no more than once per provider. per discipline. Therefore. Therapeutic exercise and activities are essential for rehabilitation. The codes allowed 0 units in the column for “Allowed Units.. an overall course of rehabilitative therapy is expected to consist predominantly of therapeutic procedures (such as codes 97112. 97004) with the appropriate evaluation/revaluation. 97116 88 Indications and Limitations of Coverage and/or Medical Necessity  Rev.g..” may not be billed under a plan of care indicated by the discipline in that column. per date of service. codes 97032–97039 require direct (one-on-one) contact with the patient by the qualified professional. Allowed Units CPT Code 97001© 97002© 97003© 97004© 97005© 97006© Code Description Pt evaluation Pt re-evaluation Ot evaluation Ot re-evaluation Timed/Untimed PT Untimed Untimed Untimed Untimed 1 1 0 0 OT 0 0 1 1 SLP 0 0 0 0 Physician/NPP Not Under a Therapy POC N/A N/A N/A N/A Athletic training evaluation Athletic training re-evaluations These codes are not payable by Medicare.g. physicians may not report any of these codes in conjunction with an evaluation and management code performed on the same day. non-physicians and/or physical/occupational therapist). However. codes 99212–99215..g. General Modality Guidelines (Codes 97012 and 97018–97039)  Modality codes 97012 and 97016–97028 require supervision by the qualified professional. It is expected these services will be infrequently required. Evaluations 97001© 97002© 97003© 97004© Pt evaluation Pt re-evaluation Ot evaluation Ot re-evaluation These services are separately billable under one of the three different types of practitioners (physicians. The use of modalities as stand-alone treatment is not indicated as a sole approach to rehabilitation. per patient. Some codes may be billed by one discipline (e. occupational therapy or speech-language pathology). 97002. physical therapy) and not by others (e.

Generally. Exceptions could include musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation supporting the medical necessity and clinical justification for the services’ continued use must be made available to Medicare upon request. reduce inflammation and edema. Medicare would not expect to see multiple heating modalities billed routinely on the same day. it is expected that modalities will compromise a small portion of the total therapy service time involved during the course of rehabilitative therapy. inflammation or edema. Documentation must be available supporting the use of multiple modalities as contributing to the patient’s progress and restoration of function. one to two visits may be medically necessary to determine the effectiveness of treatment and for patient education). When modality codes 97012 and 97018 are used alone (absent therapeutic procedures and not a precursor to active treatment) and solely to promote healing. adjunctive use of services billed with modality codes 97012 and 97018 is coverable only if they enhance the therapeutic procedures. increasingly active therapeutic treatment. Generally. Although passive modalities play a role in the early stages of rehabilitation and in treating exacerbation. with adjunctive use of modalities. Medicare does not provide payment for the therapeutic modality described as phonophoresis. one or two visits may be medically necessary to determine the effectiveness of a limited number of visits (e. It is usually not medically reasonable and necessary to continue modality-only treatment by the qualified professional. Medicare does not provide payment for the therapeutic modality described as iontophoresis. Anodyne therapy is non-covered (see “Non-Covered LCD). relieve muscle spasm. it is expected that the record will demonstrate both the patient’s clinical progress and concomitant appropriate. only one hydrotherapy modality is coverable per day when the sole purpose is to relieve muscle spasm. 97026 and 97035 on the same day is essential. Because some of the modalities are not separately reimbursed. or as analgesia. Documentation containing clinical justification supporting the medical necessity for multiple heating modalities such as codes 97018.MEDICARE PART B Therapy Services and/or 97530). 97024.g. refer to “National Correct Coding Initiative (NCCI)” within the “Modifiers” section of this manual.         Specific Modality Guidelines Refer to the “ICD-9-CM Codes That Support Medical Necessity” section for appropriate covered diagnoses to be used with these modalities at: Rev.. it may be medically necessary to furnish these modalities in addition to the therapeutic procedures for up to 16 sessions in one month. In these circumstances. 01/2012 89 Indications and Limitations of Coverage and/or Medical Necessity . only one heating modality is coverable per day. Further. Generally. Treatment with infrared therapy (97026) is non-covered.

MEDICARE PART B
Therapy Services
http://www.trailblazerhealth.com/Tools/LCDs.aspx Select appropriate program and state, and then click on “T” for the “Therapy Services (PT, OT, and SLP)” LCD. Advance Beneficiary Notice of Noncoverage (ABN) The Advance Beneficiary Notice of Noncoverage (ABN) applies to therapy services. For complete ABN instructions, refer to the CMS Web Resources Advance Beneficiary Notice of Noncoverage (ABN) Booklet at: http://www.cms.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.pdf The following clinical guidelines pertain to the specific modalities listed. G0283 – This modality includes the following types of electrical stimulation:  Transcutaneous Electrical Nerve Stimulation (TENS).  Microamperage E-Stimulation (MENS).  Percutaneous Electrical Nerve Stimulation (PENS).  Electrogalvanic stimulation (high-voltage pulsed current).  Functional electrical stimulation.  Interferential current/medium current. Note: This code should be used for unattended electrical stimulation. These types of electrical stimulation may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function. Electrical stimulation must be utilized with appropriate therapeutic procedures (e.g., 97110) to effect continued improvement. Electrical stimulation is typically used in conjunction with therapeutic exercises. It is expected this modality will be used in a clearly adjunctive role and not as a major component of the therapeutic encounter. When electrical stimulation is used for muscle strengthening or retraining, the nerve supply to the muscle must be intact. It is not medically necessary for completely denervated motor nerve disorders in which there is no potential for recovery or restoration of function. 97010© Hot or cold packs therapy

This procedure is bundled into the payment for all other services including, but not limited to, office visits and physical therapy. It is never paid separately.
Rev. 01/2012 90 Indications and Limitations of Coverage and/or Medical Necessity

MEDICARE PART B
Therapy Services
97012© Mechanical traction therapy

This modality, when provided by physicians or independent physical therapists, is typically used in conjunction with therapeutic procedures, not as an isolated treatment; however, it may be used in weaning an acute patient to a self-administered home program. 97014© Electric stimulation therapy

Note: This code is not recognized by Medicare; refer to code G0283 or 97032 for billing codes for electric stimulation services. 97016© Vasopneumatic device therapy

Education for the home use of a lymphedema pump usually requires one to two sessions and is sometimes provided by the lymphedema pump supplier. If the supplier does not provide this treatment, provision will be made for one educational and one follow-up visit. Medicare would not expect to be billed for lymphedema treatments. Medicare expects that documentation in the physician’s medical record must support the necessity of this modality and must be made available to Medicare upon request. For requirements on lymphedema therapy, see TrailBlazer’s LCD, “Complex Decongestive Physiotherapy (CDP) for Lymphedema.” 97018© Paraffin bath therapy

Also known as hot wax treatment, this service is primarily used for pain relief in chronic joint problems of the wrists, hands or feet. One or two treatments are usually sufficient to educate the patient in home use and to evaluate effectiveness. A third visit will be allowed to ensure adequate education and technique of patient and caretakers with documentation of a systemic illness such as rheumatoid arthritis. This modality may be medically necessary as an adjunct to other physical/occupational therapy interventions. Documentation supporting the medical necessity for additional treatments must be made available to Medicare upon request. 97022© 97036© Whirlpool therapy Hydrotherapy

These modalities involve the use of agitated water to relieve muscle spasms, improve circulation or cleanse wounds (e.g., ulcers, exfoliative skin conditions).  Physician or therapist supervision of the whirlpool modality must be medically necessary for the following indications:

Rev. 01/2012

91

Indications and Limitations of Coverage and/or Medical Necessity

MEDICARE PART B
Therapy Services
o The patient’s condition is complicated by:  Circulatory deficiency.  Areas of desensitization.  Impaired mobility or limitations in the positioning of the patient.  Concerns about safety if left unsupervised. Documentation supporting the medical necessity for additional sessions must be made available to Medicare upon request. It is not medically necessary to have more than one form of hydrotherapy during a treatment session. Diathermy (e.g., microwave)

 

97024©

Because there is no evidence from published, controlled clinical studies demonstrating the efficacy of microwave therapy, Medicare would not expect to see this billed. 97026© Infrared therapy

This is a non-covered service. 97028© Ultraviolet therapy

Ultraviolet must be prescribed by the attending physician. Minimal erythema dosage must be documented and made available to Medicare upon request. 97032© Electrical stimulation

See procedure code G0283 for clinical guidelines for this procedure. This code should be used for unattended electrical stimulation. 97033© Iontophoresis

Because there is no evidence from published, controlled clinical studies demonstrating the efficacy of this as a physical medicine modality, the service represented by code 97033 will be denied as not proven safe and effective. 97034© Contrast bath therapy

This modality may be useful to treat extremities affected by:  Reflex sympathetic dystrophy.  Acute edema resulting from trauma.  Synovitis/tenosynovitis. Note: Generally used as an adjunct to a therapeutic procedure.
Rev. 01/2012 92 Indications and Limitations of Coverage and/or Medical Necessity

trailblazerhealth.com/Tools/LCDs. OT. a complete narrative description (detailing the service or procedure being performed) must be included on the claim. affected by the use of each of these procedures. 97113 or 97530 may be used in a treatment plan. since any one or a combination of more than one of codes 97110. Codes 97110.aspx Rev. 97039© Physical therapy treatment For all claims submitted with an unlisted modality code. Documentation supporting the medical necessity for continued treatment must be made available to Medicare upon request. The expected goals documented in the treatment plan. documentation must support the use of each code as it relates to specific therapeutic goal(s). Standard treatment is up to 16 sessions within one month as an adjunctive modality to therapeutic exercise. 01/2012 93 Indications and Limitations of Coverage and/or Medical Necessity . 97112.MEDICARE PART B Therapy Services 97035© Ultrasound therapy This modality is used primarily to:  Treat arthritis. Use of these procedures requires that the practitioner have direct (one-on-one) patient contact. This code applies only to a procedure in which constant attendance was a requisite.  Treat neuromas. will help define whether these procedures are reasonable and medically necessary. Therefore.  Specific Guidelines for Therapeutic Procedures The following clinical guidelines pertain to the specific listed therapeutic procedures.  Treat inflammation of periarticular structures. SLP)” LCD for appropriate covered diagnoses to be used with these therapeutic procedures at: http://www.  Soften adhesive scars. Refer to the “ICD-9-CM Codes That Support Medical Necessity” section in the “Therapy Services (PT. General Guidelines for Therapeutic Procedures (97110–97546)    Therapeutic procedures are procedures that attempt to reduce impairment and improve function through the application of clinical skills and/or services. The treatment plan must be maintained in the patient’s medical record and made available to Medicare upon request. 97113 and 97530 describe several different types of therapeutic interventions. 97112.

08 (profound impairment in both eyes. strength.g. The exercise may be reasonable and medically necessary for a loss or restriction of joint motion. a person with an ICD-9CM diagnosis of 369. strength or mobility (e. stretching. including low-vision services.  Mobility.. 01/2012 94 Indications and Limitations of Coverage and/or Medical Necessity . lumbar stabilization. activeassisted or passive (e. strength grades. degrees of motion. levels of assistance). This therapeutic procedure is measured in 15-minute units with therapy sessions frequently consisting of several units.  Other medically necessary services. meal preparation.  Activities of daily living. Some of the following rehabilitation programs/services for beneficiaries with vision impairment may include Medicare-covered therapeutic services. functional capacity or mobility that has resulted from a specific disease or injury. i.e. activities of daily living.MEDICARE PART B Therapy Services Advance Beneficiary Notice of Noncoverage (ABN) The ABN applies to therapy services. For complete ABN instructions.pdf Rehabilitation for Vision Impairment In accordance with established conditions. For example. rehabilitation services under CPT/HCPCS code 97535 (self-care/home management training. and may be provided.e.g. The patient must have a potential for restoration or improvement of lost functions.gov/MLNProducts/downloads/ABN_Booklet_ICN006266.. strengthening). best corrected visual acuity is less than 20/400 or visual field is 10 degrees or less) would generally be eligible for. compensatory training. 97110© Therapeutic exercises To develop strength and endurance. and must be expected to improve significantly within a reasonable and generally predictable amount of time. Documentation must show objective loss of joint motion. refer to the CMS Web Resources Advance Beneficiary Notice of Noncoverage (ABN) Booklet at: http://www..cms. and maintenance therapy – services required to maintain a level of functioning – is not covered. all rehabilitation services to beneficiaries with a primary vision impairment diagnosis must be provided pursuant to a written treatment plan established by a Medicare physician and implemented by approved Medicare qualified professionals (occupational or physical therapists) or as “incident to” physician services.. Rehabilitation services are not covered if the patient is unable to cooperate in the treatment program or if clear goals are not definable. 97112© Neuromuscular re-education Rev. range of motion and flexibility: active. safety procedures and instruction in the use of adaptive equipment). treadmill. i. Most rehabilitation is short-term and intensive. isokinetic exercise.

The procedure may be reasonable and medically necessary for a loss or restriction of joint motion.. Bobath.g. proprioceptive neuromuscular facilitation. It is not medically necessary to employ hydrotherapy and aquatic therapy during the same treatment session. resistance). levels of assistance). posture and proprioception (e. kinesthetic sense. strength. Note: Hydrotherapy refers to codes 97022 and 97036.g. This procedure is not reasonable and necessary or medically necessary when the patient’s walking ability is not expected to improve.. mobility or function that has resulted from a specific disease or injury. Documentation must be available in the record to support medical necessity. strength grades. When aquatic therapy is provided in a community pool. or when aquatic therapy facilitates progress to land-based exercise or increased function. muscular or skeletal abnormalities or trauma. BAP’s boards and desensitization techniques). 01/2012 95 Indications and Limitations of Coverage and/or Medical Necessity .g. buoyancy. debridement of ulcers).. 97113© Aquatic therapy/exercises This procedure uses the therapeutic properties of water (e. loss of gross and fine motor coordination. Other forms of exercise therapy may be medically necessary in addition to aquatic therapy when the patient cannot perform land-based exercises effectively to treat his condition without first undergoing the aquatic therapy. Documentation must show objective loss of joint motion. degrees of motion. Do not use this code for situations where no exercise is being performed in the water environment (e. poor static or dynamic sitting/standing balance.g..g. Repetitive walk-strengthening exercises for feeble or unstable patients or to increase endurance do not require qualified professional supervision and will be denied as not Rev. the provider must rent or lease at least a portion of the pool for the exclusive use of the patients. The procedure may be reasonable and medically necessary for impairments that affect the body’s neuromuscular system (e. hypo/hypertonicity).MEDICARE PART B Therapy Services This therapeutic procedure is provided to improve balance. Feldenkreis.. coordination. 97116© Gait training therapy This procedure may be medically necessary for training patients whose walking abilities have been impaired by neurological. strength or mobility (e.

Documentation of the severity of the pulmonary condition and referral by the physician must be available. If the attending physician determines that for the safe and effective administration of these procedures.MEDICARE PART B Therapy Services reasonable and necessary. 01/2012 96 Indications and Limitations of Coverage and/or Medical Necessity . controlled clinical studies demonstrating the efficacy of this modality. Generally. The treatment plan must be maintained in the patient’s medical record and made available to Medicare upon request. Myofascial Release/Soft Tissue Mobilization This procedure may be medically necessary for the treatment of restricted motion of soft tissues involving the extremities. However. Example: Report phonophoresis with HCPCS code 97139.aspx In most cases.com/Tools/LCDs. coverage may be allowed. if a service represented by code 97760 was performed on an upper extremity and a service represented by code 97116 (gait training) was also performed. both codes may be billed with modifier 59 to denote separate anatomic sites. phonophoresis will be denied as not proven safe and effective. improve joint motion. the professional skills of a PT are required. manual traction and manual lymphatic drainage. reduce edema. Skilled manual techniques (active Rev. manipulation. HCPCS code 97116 should not be reported with 97760. or for relief of muscle spasm. which is designed to restore muscle function.trailblazerhealth. treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home setting. (Manual lymphatic drainage is addressed in a separate TrailBlazer policy. 97124© Massage therapy This procedure may be medically necessary as adjunctive treatment to another therapeutic procedure on the same day.) For cervical radiculopathy. neck and/or trunk. see TrailBlazer’s LCD “Outpatient Pulmonary Rehabilitation” at: http://www. Manual therapy 97140© Manual therapy such as mobilization. However. because there is no evidence from published. and therefore is not a covered service. a complete narrative description (detailing the service or procedure being performed) must be included on the claim. postural drainage and pulmonary exercises can be carried out safely and effectively by ancillary personnel. 97139© Physical medicine procedure For all claims submitted with an unlisted procedure code. For manipulation of chest wall (94667).

how the treatment technique will restore function. Manipulation CPT description for code 97140 includes manual therapy and techniques such as manipulation.  Restoration of movement in acutely edematous. The physician or therapist involved in group therapy services must be in constant attendance. the frequency and duration of the particular group setting and the treatment goal in the individualized (patient specific) plan. soft tissue mobilization or joint mobilization. Documentation supporting the medical necessity for continued treatment must be made available to Medicare upon request. 01/2012 97 Indications and Limitations of Coverage and/or Medical Necessity . The Rev. 97112 or 97530.  Stretching of shortened connective tissue. articular structures. group therapy sessions (two or more patients) should be of sufficient length to address the needs of each of the patients in the group. Joint Mobilization This procedure may be medically necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure. All techniques applied on the same date of service should be totaled into the time calculated for the code. CPT description for code 97140 includes manual therapy and techniques such as manipulation. 97112 or 97530. This procedure may be medically necessary as an adjunct to other therapeutic procedures such as codes 97110. Individual techniques should not be separately coded or billed since it is a time-based code. medically necessary services will be provided as appropriate to each patient’s plan of care. but one-on-one patient contact is not required. Documentation must identify the specific treatment technique(s) used in the group. neural or vascular systems. soft tissue mobilization or joint mobilization. Examples include:  Facilitation of fluid exchange. Therefore. All techniques applied on the same date of service should be totaled into the time calculated for the code. Individual techniques should not be separately coded or billed since it is a time-based code.MEDICARE PART B Therapy Services and/or passive) are applied to effect changes in the soft tissues. Medicare expects that skilled. muscles. This procedure may be medically necessary as an adjunct to other therapeutic procedures such as those represented by code 97110. 97150© Group therapeutic procedures In the case of group therapy (untimed).

g. One-on-One Example: In a 45-minute period. 01/2012 98 Indications and Limitations of Coverage and/or Medical Necessity . then patient B for five more minutes (13 minutes total) and patient C for six additional minutes (14 minutes total). b. they are each exercising independently. the therapist returns to work with patient A for 10 more minutes (18 minutes total). If the therapist is dividing attention among the patients. the therapist bills for individual therapy and counts the total minutes of service to each patient in order to determine how many units of service to bill each patient for the timed codes. Each direct one-on-one episode. Group Example: In a 25-minute period. patient B receives eight minutes and patient C receives eight minutes. should be of a sufficient length of time to provide the appropriate skilled treatment in accordance with each patient’s plan of care. a therapist works with three patients.. Rev. Group Therapy vs. intermittent personal contact. The therapist moves back and forth between the two patients. providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives eight minutes. a therapist works with two patients. and divides his time between the patients. the manner of practice should clearly distinguish it from care provided simultaneously to two or more patients. and provides occasional assistance and modifications to patient A’s exercise program and offers verbal cues for patient B’s gait training and balance activities in the parallel bars. When direct one-on-one patient contact is provided. During the times the patients are not receiving direct one-on-one contact with the therapist. five minutes later). or giving the same instructions to two or more patients at the same time. Individual Therapy The following is provided to assist providers in determining whether to bill for group therapy (97150) or individual therapy (defined by the timed CPT codes for therapeutic procedures requiring direct one-on-one patient contact) when treating two patients during the same time period. 97150 (untimed). it is appropriate to bill each patient one unit of group therapy. spending a minute or two at a time. The therapist does not track continuous or notable. After this initial 24-minute period. Also. These direct one-onone minutes may occur continuously (15 minutes straight) or in notable episodes (e. however. a.MEDICARE PART B Therapy Services number of persons in the group must also be documented. Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. The therapist appropriately bills each patient one 15-minute unit of therapeutic exercise (97110) corresponding to the time of the skilled intervention with each patient. These records must be made available to Medicare upon request. A. B. 10 minutes now. providing only brief. and C. A and B. identifiable episodes of direct one-on-one contact with either patient and would bill each patient one unit of group therapy (97150) corresponding to the time of the skilled intervention with each patient.

01/2012 99 Indications and Limitations of Coverage and/or Medical Necessity . 97533© Sensory integrative techniques This activity focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands. and is part of an active treatment plan directed at a specific goal. is designed to address specific needs of the patient. balance or coordination. strength. 97532© Cognitive skills development This activity focuses on cognitive skills development to improve attention. reaching. with direct one-on-one patient contact by the qualified professional. carrying. lifting.MEDICARE PART B Therapy Services 97530© Therapeutic activities This procedure involves using functional activities (e. These dynamic activities must be part of an active treatment plan and directed at a specific outcome. PTs and OTs may be covered if separate and distinct goals are documented in the treatment plans. 97535© Self care management training This procedure is medically necessary only when it requires the professional skills of a qualified professional. each 15 minutes. with direct one-on-one contact by the qualified professional. Services provided concurrently by physicians. catching and overhead activities) to improve functional performance in a progressive manner. Documentation supporting the medical necessity for continued treatment must be made available to Medicare upon request. memory. each 15 minutes.. problem solving. bending. and an integrated treatment plan is maintained by the requesting physician. The activities are usually directed at a loss or restriction of mobility. Documentation must relate the training to expected functional goals the patient can attain.g. 97537© Community/work reintegration training This training may be medically necessary when performed in conjunction with a Rev. The patient or caregiver must have the capacity to learn from instructions. They require the professional skills of a qualified professional and are designed to address a specific functional need of the patient.

Documentation of medical necessity must be available on request for an unusual frequency or duration of training sessions. Generally speaking. 97545© 97546© Work hardening/conditioning Work hardening/conditioning add-on These services are related solely to specific work skills and will be denied as not medically necessary for the diagnosis or treatment of an illness or injury.MEDICARE PART B Therapy Services patient’s individual treatment plan aimed at improving or restoring specific functions that were impaired by an identified illness or injury. Services that are related solely to specific employment opportunities. This training is medically necessary only when it requires the professional skills of a qualified professional. 97750© Physical performance test This testing may be medically necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific treatment plan or to determine a patient’s capacity. When billing code 97542 for wheelchair propulsion training. up to four sessions within one month is sufficient. work skills or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by Section 1862(a)(1) of the SSA. General activity programs and all activities that are primarily social or diversional in nature will be denied because the professional skills of a qualified professional are not required. The patient or caregiver must have the capacity to learn from instructions. and when expected outcomes that are attainable by the patient are specified in the plan. Typically. The patient’s medical record must document the problem requiring tests. 97542© Wheelchair management training This procedure is medically necessary only when it requires the professional skills of a qualified professional. 01/2012 100 Indications and Limitations of Coverage and/or Medical Necessity . documentation must relate the training to expected functional goals the patient can attain. is designed to address specific needs of the patient. and is part of an active treatment plan directed at a specific goal. the professional skills of a qualified professional are not required to effect improvement or restoration of function when a patient suffers a temporary loss or reduction of function that could reasonably be expected to improve as the patient gradually resumes normal activities. the specific Rev.

MEDICARE PART B Therapy Services tests performed and a measurement report. 01/2012 101 Indications and Limitations of Coverage and/or Medical Necessity . It is unusual to require more than 30 minutes of prosthetic training per day. pain. skin breakdown. Documentation supporting the medical necessity for additional time must be made available to Medicare upon request. or self-care/home management training (97535). It is unusual to require more than 30 minutes of static orthotics training. 97761© Prosthetic training The medical record should document the distinct goal(s) and service(s) rendered when prosthetic training for a lower extremity is performed during the same treatment session as gait training (97116) or self-care/home management training (97535).g. direct one-on-one contact with the qualified professional and with written report. both codes may be billed with modifier 59 to denote separate anatomic sites. each 15 minutes. 97755© Assistive technology assess Assistive technology assessment.. Documentation must be submitted with the claim identifying the need for more than 30 minutes of time. to restore. HCPCS code 97116 should not be reported with 97760. augment or compensate for existing function. dynamic training may require additional time. 97762© C/O for orthotic/prosth use These assessments may be medically necessary when a device is newly issued or there is a modification or reissue of the device. Documentation supporting the medical necessity for additional time must be made available to Medicare upon request. Generally. 97760© Orthotic mgmt and training The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is performed during the same treatment session as gait training (97116). However. Rev. optimize functional tasks. In some cases. These assessments may be medically necessary when patients experience loss of function directly related to the orthotic or prosthetic device (e. if a service represented by code 97760 was performed on an upper extremity and a service represented by code 97116 (gait training) was also performed.

the medical record shall contain information outlined in Pub. This documentation should establish the variables that influence the patient’s condition.  Outpatient therapy must be under the care of a Physician/NPP. maintained in the patient’s medical record and made available to Medicare upon request. provides evidence of both the need for care and that the patient is under the care of a physician.MEDICARE PART B Therapy Services or falls).  Note: If results of one of the four instruments listed above are not recorded.100-02. All qualified professionals rendering therapy must document the appropriate history. An order (sometimes called a referral) for therapy service. the date therapy was initiated. the body areas to be treated. and expected frequency and number of treatments.3. (FOTO). Documentation Requirements  Documentation supporting the medical necessity should be legible. especially those factors that influence the clinician’s decision to provide more services that are typical for the individual’s condition. Section 220.C:  The medical record must identify the physician responsible for the general medical care. examination. functional assessment. 97799© Physical medicine procedure For all claims submitted with an unlisted procedure code. Documentation must be submitted with the claim identifying the need for more than 30 minutes of time. The treatment plan must be maintained in the patient’s medical record and made available to Medicare upon request. o Activity Measure – Post Acute Care (AM-PAC). a complete narrative description (detailing the service or procedure being performed) must be included on the claim. Results of one of the following four measurements are recommended: o National Outcomes Measurement System (NOMS) by the American SpeechLanguage-Hearing Association. diagnosis. Documentation should establish through objective measurements that the patient is making progress toward goals. Chapter 15. type of treatment. 01/2012 102 Indications and Limitations of Coverage and/or Medical Necessity . o Patient Inquiry by Focus on Therapeutic Outcomes. Inc. documented in the medical record.  Therapy services must be furnished according to a written treatment plan determined by the physician or by the therapist who will provide the treatment after an appropriate assessment of the condition (illness or injury). o OPTIMAL by Cedaron through the American Physical Therapy Association. Payment is dependent on the certification of the plan of Rev.

per discipline. A dated notation of a verbal order to certify the plan of care should be made in the patient’s medical record. Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time or the need to establish a safe and effective maintenance program.MEDICARE PART B Therapy Services care rather than the order. Evaluation. For CMS recommendations regarding progress reports and modifications to the plan of care. When both a modality/procedure and an evaluation service are billed. When a verbal order is used to certify the plan of care. when compared. Evidence considered necessary to justify delayed certification should be maintained by the supplier of services. re-evaluation and assessment documented in progress notes should describe objective measurements that. even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings. When therapy services are billed as “incident to” a physician’s/NPP’s services. Signature and professional identity of the person who established the plan and the date it was established must be recorded with the plan. Recertifications must be obtained within the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan. Certification is the physician’s/NPP’s approval of the plan of care. refer to the Medicare Benefit Policy Manual. the requirement for direct supervision by the physician/NPP and other “incident to” requirements must be met. 01/2012 . Signature and professional identity of the person who established the plan and 103 Indications and Limitations of Coverage and/or Medical Necessity              Rev. IOM Pub. 100-02. show improvement in function or decrease in severity or rationalization for an optimistic outlook to justify continued treatment. 97034) on the same date of service must be available for review and show that all were needed toward the restoration of function. Allowed unit limitations (once per provider. Chapter 15. 97026. 97024. Evidence considered necessary to justify delayed certification should be maintained by the supplier of services. a dated notation should be made in the patient’s medical record. A certification is timely when it is obtained within 30 calendar days of the initial treatment under that plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. per patient) by discipline for CPT codes. whichever is less. Documentation supporting the medical necessity for multiple heating modalities (codes 97018. per date of service. the evaluation may be reimbursed if the medical necessity for the evaluation is clearly documented. but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.

For claims submitted by a PT. Further. independent PTs and OTs may bill for physical medicine services using the HCPCS physical medicine and rehabilitation codes. however. Similarly. Additionally. Provisions of this LCD do not take precedence over CCI edits.  Sixty (15 minutes each) OT services per patient per month. Reminders Coding Guidelines   All coverage criteria must be met before Medicare can reimburse this service.  Five (15 minutes each) timed OT services per patient per day. each service must be medically reasonable and necessary for the specific patient and his condition. Any federally established financial limitations on outpatient therapy services’ coverage and coding rules will apply. 2010. Physicians. even when reported at a frequency within the following stated covered guidelines. Medicare does not expect that maximum allowable services will be routinely necessary. Medicare expects that the patient’s medical record will clearly demonstrate that medical necessity. Refer to the Correct Coding Initiative (CCI) for correct coding guidelines and specific applicable code combinations prior to billing Medicare. services in addition to the above limits may be payable when medical review of the patient’s record that demonstrates medical necessity for additional services. OT.  Sixty (15 minutes each) PT services per patient per month.MEDICARE PART B Therapy Services  the date it was established must be recorded with the plan. The total number of timed minutes must be documented in the medical record. OT or SLP in independent practice. Likewise. Utilization Guidelines Effective for services rendered on or after May 17. an order. SLP)” LCD provides authority for automated claim denial of claims for services in excess of the following:  Five (15 minutes each) timed PT services per patient per day. may be denied if done so in association with medical review of the patient’s record that demonstrates no medical necessity for the services. 01/2012 . or necessary for the entirety of the patient’s course of treatment. 104 Indications and Limitations of Coverage and/or Medical Necessity   Rev. necessary for multiple-week periods. Refer to the Correct Coding Initiative (CCI) for specific code(s) that are bundled and not separately payable. providers of PT/OT services must understand that although Medicare will allow the following units of service. that any service reported to Medicare. the “Therapy Services (PT. Providers of PT/OT services must be aware.

does not meet indications of the related LCD). The services must be of such a level of complexity and sophistication or the condition of the patient must be such that the services required can be safely and effectively performed only by a qualified therapist or under his supervision.)  GZ – Waiver of liability statement is not on file. To bill the patient for services that are not covered (investigational/experimental or not reasonable and necessary) will generally require an Advance Beneficiary Notice (ABN) be obtained before the service is rendered.4 and not the diagnosis code for the cardiac condition.MEDICARE PART B Therapy Services sometimes called a referral. 799. all claim line items submitted with a GZ modifier shall be denied automatically and will not be subject to complex medical review.2. Payable rehabilitation services (as per IOM Pub. o Modifiers:  GA – Waiver of liability statement issued. For example: o When patients have become deconditioned because of prolonged inactivity (as a result of an illness). provides evidence of both the need for care and that the patient is under the care of a physician.) (ABN does not have to be submitted but must be made available upon request. and must be coded to the highest level of specificity for that date of service. The diagnosis code(s) must be representative of the patient’s condition. 01/2012 . When billing for this service in a non-covered situation (e.g. OT or SLP services. for therapy service.) Effective July 1. Services which do not require the performance or supervision of a therapist are not considered reasonable or necessary services. (Use for patients who do not meet the covered indications and limitations and who did not sign an ABN. use the appropriate HCPCS or CPT code(s). if it is documented in the medical record. not the underlying condition. 2011. To report services. OT or SLP and must be reasonable and necessary to the treatment of the individual’s illness or injury. use the appropriate “V” codes for surgical aftercare. Chapter 15. Section 230): “To be covered PT. o For aftercare of corrective surgery for deformities. as required by payer policy (Use for patients who do not meet the covered indications and limitations and has an ABN is on file. the services must relate directly and specifically to an active written treatment regimen established by the physician or non-physician practitioner after any needed consultation with the qualified PT. use the appropriate modifier (see below).3 or 799..” Diagnosis(s) must be present on any claim submitted. 100-02. not the diagnosis codes for the congenital or 105 Indications and Limitations of Coverage and/or Medical Necessity       Rev. use ICD-9-CM diagnosis codes such as 728. When PM&R services are performed for patients who have suffered musculoskeletal or neurological complications secondary to some other disease use the diagnosis reflecting the reason for the encounter.

When physicians/NPPs bill “always therapy” codes. bill the allowed units (refer to Reporting Units of Service in the Modifier section of this manual) for physical therapy. Refer to the “Reporting Units of Service” section in this manual. but not limited to. then the total number of units that can be billed is constrained by the total treatment time. per day. Use the following modifiers when billing outpatient rehabilitation services: o GN – Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care. but as a medical service. If more than one CPT code is billed during a calendar day. then the total treatment time was 47 minutes. the therapy modifier shall not be used.g. bill with the appropriate therapy modifier (GP. A physician/NPP shall not bill an “always therapy” code unless the service is provided under a therapy plan of care. o GP – Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care. For example. GO. 01/2012 106 Indications and Limitations of Coverage and/or Medical Necessity . It is never paid separately. office visits and physical therapy.      Reasons for Denial  If an individual’s expected rehabilitation potential would be insignificant in relation to the extent and duration of physical therapy services required to achieve such potential.MEDICARE PART B Therapy Services acquired deformity. they must follow the policies of the type of therapy they are providing. if 24 minutes of code 97112 and 23 minutes of code 97110 were furnished. per provider/supplier. When a “sometimes therapy” code is billed by a physician/NPP. o Use the ICD-9-CM diagnosis codes for muscle spasm or contractures when they are the complications of another disorder. e. GN). therapy would not be covered because it is not considered rehabilitative or reasonable and necessary.  Rev. Documentation in the medical record must support the diagnoses or patient factors that influenced the need for the therapy services that exceeded the cap. but the number of units billed must not exceed the number of units indicated in the table per patient. Procedure code 97010 is bundled into the payment for all other services including. o GO – Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care. so only three units can be billed for the treatment. assigning more units to the service that took the most time. occupational therapy or speech-language pathology depending on the plan.. The correct coding is two units of code 97112 and one unit of code 97110. Include the KX modifier on the claim for medically necessary services that exceed the limitations established by federal law. utilize a plan of care. and not under a therapy plan of care.

MEDICARE PART B
Therapy Services
 Because there is no evidence from published, controlled clinical studies demonstrating the efficacy of this as a physical medicine modality, the service represented by code 97033 will be denied as not proven safe and effective. Medicare has determined that as a therapy, hot and cold packs are easily selfadministered, more commonly used in the home and generally not covered. Because there is no evidence from published, controlled clinical studies demonstrating the efficacy of microwave therapy, Medicare would not expect to see this billed. Heat modalities (codes 97024 and 97035) for the treatment of pulmonary conditions will be non-covered as not medically reasonable and necessary. Electrical stimulation (codes 97014 and 97032) is considered not reasonable and necessary for motor nerve disorders such as Bell’s palsy. Due to the duplication of services represented by the code for manual manipulation, soft tissue mobilization, joint mobilization (code 97140) and the codes for osteopathic manipulation (98925–98929), separate payment will not be allowed if any of these codes are reported for the same patient on the same date of service. When physical or occupational therapy is performed for a hospital inpatient by a physical or occupational therapist, the service is not payable under the contractor physician fee schedule. For a physician to be reimbursed for one of these services, the service must be personally performed by the physician. The service is not payable if it is performed under the physician’s supervision by auxiliary personnel as “incident to” the physician’s service, but instead is bundled into the hospital payment. Services that can be safely and effectively furnished by non-skilled personnel or by Physical Therapy Assistants (PTAs) or Occupational Therapy Assistants (OTAs) without the supervision of therapists are not rehabilitative therapy services. Services determined not to be medically necessary when reviewing claims for services excepted from the therapy caps due to identification of a pattern of aberrant billing or during normal pre- and post-payment medical review. Conditions not accepted as standards of practice within the physician community or supported by peer-reviewed literature will be non-covered. Service(s) rendered is not consistent with accepted standards of medical practice. The medical record does not verify the service described by the CPT/HCPCS code was provided. The service is considered: o Investigational. o For routine screening.

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Rev. 01/2012

107

Indications and Limitations of Coverage and/or Medical Necessity

MEDICARE PART B
Therapy Services
o A program exclusion. o Otherwise not covered. o Never medically necessary.

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108

Indications and Limitations of Coverage and/or Medical Necessity

MEDICARE PART B
Therapy Services MULTIPLE PROCEDURE PAYMENT REDUCTION (MPPR) FOR SELECTED THERAPY SERVICES

Background
Section 3134 of the Affordable Care Act (ACA) added Section 1848(c)(2)(K) of the Social Security Act, which specifies that the Secretary shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. As a step in implementing this provision, Medicare is applying a new Multiple Procedure Payment Reduction (MPPR) to the Practice Expense (PE) payment of select therapy services paid under the physician fee schedule. The reduction will be similar to that currently applied to multiple surgical procedures and to diagnostic imaging procedures. This policy is discussed in the CY 2011 physician fee schedule proposed rule published July 13, 2010. This advance notice is provided so contractors can begin making the necessary systems changes for the policy to go in effect January 1, 2011.

Policy
Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The MPPR is being applied to the PE payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures. Full payment is made for the unit or procedure with the highest PE payment. For subsequent units and procedures, furnished to the same patient on the same day, full payment is made for work and malpractice and 80 percent payment for the PE for services furnished in office settings and other non-institutional settings (services paid under Section 1848 of the Act) and 75 percent payment for the PE for services furnished in institutional settings. For therapy services furnished by a group practice or “incident to” a physician’s service, the MPPR applies to all services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines, for example, physical therapy, occupational therapy, or speech-language pathology. The reduction applies to the HCPCS codes contained on the list of “always therapy” services that are paid under the physician fee schedule, regardless of the type of provider or supplier that furnishes the services (e.g., hospitals, home health agencies and Comprehensive Outpatient Rehabilitation Facilities (CORFs), etc.) The MPPR applies to the procedures listed below.

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MPPR for Selected Therapy Services

microwave Infrared therapy Ultraviolet therapy Electrical stimulation Electric current therapy Contrast bath therapy Ultrasound therapy Hydrotherapy Therapeutic exercises Neuromuscular reeducation Aquatic therapy/exercises Gait training therapy Massage therapy Manual therapy Group therapeutic procedures Therapeutic activities Sensory integration Self care mngment training Community/work reintegration Wheelchair mngment training Rev. 1hr Use of speech device service Cognitive test by hc pro Pt evaluation Pt re-evaluation Ot evaluation Ot re-evaluation Mechanical traction therapy Vasopneumatic device therapy Paraffin bath therapy Whirlpool therapy Diathermy eg. 01/2012 110 MPPR for Selected Therapy Services .MEDICARE PART B Therapy Services List of Therapy Procedures Subject to Multiple Procedure Payment Reduction Listed below are the therapy procedures subject to the multiple procedure payment reduction: Code 92506© 92507© 92508© 92526© 92597© 92607© 92609© 96125© 97001© 97002© 97003© 97004© 97012© 97016© 97018© 97022© 97024© 97026© 97028© 97032© 97033© 97034© 97035© 97036© 97110© 97112© 97113© 97116© 97124© 97140© 97150© 97530© 97533© 97535© 97537© 97542© Short Descriptor Speech/hearing evaluation Speech/hearing therapy Speech/hearing therapy Oral function therapy Oral speech device eval Ex for speech device rx.

aspx Rev. To view the fee schedule and changes. refer to: http://www. 01/2012 111 Fee Scheduled Changes .trailblazerhealth.MEDICARE PART B Therapy Services FEE SCHEDULE CHANGES To accommodate the Multiple Procedure Payment Reduction policy for professional claims.com/Tools/Fee Schedule/MedicareFeeSchedule. the Medicare Physician Fee Schedule layout has changed to include this reduction.

100-04.pdf Rev.cms. 100-02.gov/manuals/Downloads/bp102c08.pdf Reference: IOM Pub. Chapter 5.gov/manuals/Downloads/bp102c15. Sections 10 and 20:  http://www. 01/2012 112 Resources . Chapters 6.pdf  http://www.cms.cms.gov/manuals/Downloads/bp102c06.MEDICARE PART B Therapy Services RESOURCES CMS Internet-Only Manual (IOM) Reference: IOM Pub. Sections 220 and 230:  http://www.cms.pdf  http://www.gov/manuals/downloads/clm104c05. 8 and 15.

com/Publications/Training Manual/HHPPS.gov/MLNProducts/downloads/How-To-Use-NCCI-Tools.cms.aspx Rev.pdf National Correct Coding Initiative (NCCI) The NCCI edits apply to therapy services.MEDICARE PART B Therapy Services ADDITIONAL RESOURCES THAT APPLY TO THERAPY SERVICES Home Health Prospective Payment System (HH PPS) The HH PPS applies to therapy services.trailblazerhealth. 01/2012 113 Additional Resources That Apply to Therapy Services .trailblazerhealth. refer to the CMS Advance Beneficiary Notice of Noncoverage (ABN) Booklet at: http://www. Refer to the Home Health Prospective Payment System (HH PPS) for additional information: http://www.gov/MLNProducts/downloads/ABN_Booklet_ICN006266. The edits will not allow certain codes to be paid on the same day as other codes. If the patient is enrolled in home health.cms. Refer to the How to Use the National Correct Coding Initiative (NCCI) Tools manual for additional information: https://www.com/Tools/LCDs.pdf TrailBlazer LCDs “Wound Care” and “Complex Decongestive Physiotherapy (CDP) for Lymphedema” LCDS can be found at: http://www. the home health agency is responsible for the therapy services.pdf Advance Beneficiary Notice of Noncoverage (ABN) For complete ABN instructions.

Added an example of the 59 modifier for therapy services. Section updated to include CR 5921. Added documentation requirements from the TrailBlazer physical therapy Local Coverage Determination (LCD). Section updated to include CR 5921. Section updated to include CR 5921.MEDICARE PART B Therapy Services REVISION HISTORY Date February 2008 Section The Financial Limitation (Therapy Cap) Modifiers Revision Section updated to include Change Request (CR) 5871. Section updated to include CR 5921. Added additional information on group therapy. Added additional Reasons for Denial. Indications and Limitations of Coverage and/or Medical Necessity    June 2008 Definition of Terms Professional Qualification Requirements Medicare Enrollment of Physical Therapists and Occupational Therapists in Private Practice Conditions of Coverage General Documentation Evaluation/ReEvaluation and Plan of Care Indications and Limitations of Coverage Section updated to include CR 5921.   Added code 96125 to Therapy Code List per CR 5810. Section updated to include CR 5921 Rev. 01/2012 114 Revision History . Section updated to include CR 5921.

Rev. Updated section to include the April 2009 update to the Physical Medicine and Rehabilitation LCD. Updated link to LCD page on the TrailBlazer Web site. Section updated to include CR 6381. Removed 30 days. Section updated to include CR 6321.MEDICARE PART B Therapy Services Date July 2008 March 2009 Section The Financial Limitation (Therapy Cap) The Financial Limitation (Therapy Cap) Modifiers Indications and Limitations of Coverage and/or Medical Necessity June 2009 Definition of Terms Professional Qualification Requirements Medicare Enrollment of Therapist in Private Practice Therapy Performed by Licensed Therapists in Private Practice Conditions of Coverage Modifiers Indications and Limitations of Coverage and/or Medical Necessity November 2009 December 2009 All Sections Definition of Terms Professional Qualification Requirements Revision Updated Cap Exception to include dates December 31. Added CMS-1500 claim form information. 2009. 01/2012 115 Revision History . Added CMS-1500 claim form information. Removed 30 days. Section updated to include revised Physical Medicine and Rehabilitation LCD. per Joint Signature Memorandum (JSM) 08387. Removed 30 days. Changed name of section and updated to include CR 6381. Section updated to include CR 6381. Changed name of section and updated to include CR 6381. Section updated to include CR 6254 and CR 6321.

Updated section to include the May 2010 update to the “Therapy Services (PT. and SLP)” LCD. Changed the name of the manual to Therapy Services. Section updated to include CR 6719. OT. Updated section to include the May 2010 update to the “Therapy Services (PT. OT. Section updated to include the Temporary Extension Act of 2010. Removed section. Updated section to include the May 2010 update to the “Therapy Services (PT. Section update with information on electrical stimulation. Section updated to include the Section 3103 of the Patient Protection and Affordable Care Act. Added new section. 01/2012 116 Revision History . Removed section. Rev. Section updated to include CR 6698 signature requirements.MEDICARE PART B Therapy Services Date Section The Financial Limitation (Therapy Cap) Modifiers March 2010 The Financial Limitation (Therapy CAP) Indications and Limitations of Coverage and/or Medical Necessity Skilled Nursing Facility Consolidated Billing (SNF CB) Home Health Prospective Payment Systems (HH PPS) Additional Resources That Apply to Therapy Services April 2010 May 2010 The Financial Limitation (Therapy CAP) Manual Title Definitions of Terms Physical Therapy Performed by a Physician/NPP Reporting Units of Service Indications and Limitations of Coverage and/or Medical Necessity Revision Section updated to include CR 6660. and SLP)” LCD. and SLP)” LCD. OT.

Rev.MEDICARE PART B Therapy Services Date August 2010 Section The Financial Limitation (Therapy CAP) Additional Resources That Apply to Therapy Services December 2010 Physical Therapy Performed by a Physician/NPP The Financial Limitation (Therapy Cap Multiple Procedure Payment Reduction (MPPR) February 2011 Indications and Limitations of Coverage and/or Medical Necessity The Financial Limitation (Therapy Cap) Revision Updated section to include CR 6980. 01/2012 117 Revision History . December 2011 Updated section to include CR 7529 and the Temporary Payroll Tax Cut Continuation Act of 2011 (TPTCCA) Updated links to the ABN and CCI manuals. New section to include CR 7050. Updated section to include CR 7107. Added Resources Added fax information. Updated section to include CR 7228.