(Medicare Benefit Policy Manual)

Medicare Benefit Policy Manual  Chapter 12 - Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage   Table of Contents  (Rev. 255, 01- 25-19)  Transmittals for Chapter 12   10 - Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by Medicare 20 - Required and Optional CORF Servic es 20.1 -  Required Services  20.2 -  Optional CORF Services  30 - Rules for Provision of Services  30.1 -  Rules for Payment of CORF Services  40 - Specific CORF Services  40.1 -  Physicians Services  40.2 -  Physical Therapy Services  40.3 -  Occupational Therapy Services  40.4  Speech Language  Pathology Services  40.5 -  Respiratory Therapy Services  40.6 -  Prosthetic and Orthotic Devices  and Supplies  40.7 -  Social and/or Psychological Services  40.8 -  Nursing Services  40.9 -  Drugs and Biologicals  40.10 -  Home Environment Evaluations  40.11 -  Vaccines  10 - Comprehensive Outpatient Rehabilitat ion Facility (CORF) Services Provided by Medicare  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  The purpose of a Comprehensive Outpatient Rehabilitation Facility (CORF) is to permit the beneficiary to receive mul tidisciplinary rehabilitation services at a single location in a coordinated fashion.  Section 1861(cc) of the Social Security Act specifies that no service may be covered as a CORF service if it would not be covered as an inpatient hospital service if provided to a hospital patient.  This does not mean that the beneficiary requires a hospital level of care or meets other requirements unique to hospital care.  This provision merely requires that the service, if otherwise covered, would be covered if provide d in a hospital.  CORF services are covered only if they relate directly to the rehabilitation for the treatment of injured, disabled, or sick patients.  CORF services are not covered if not reasonable and medically necessary for the diagnosis, or treatmen t of illness, or injury, or to improve the function of a malformed body member.  Thus, there must be potential for restoration or improvement of lost or impaired functions.  For example, treatments involving repetitive exercises (i.e., maintenance programs , general conditioning or ambulation) that do not require the skilled services of physical therapists, occupational therapists, speech -language pathologists or respiratory therapists are not covered.  Nonmedical personnel such as family members or exercise instructors could perform these activities in the patients residence.  It is not reasonable and medically necessary for such activities to be performed in a CORF setting by CORF personnel.  See 42CFR 410.100 and sections 20.1 and 20.2 of this chapter for  the list of required and optional services provided in a CORF.   CORF services do not include the following: a) provision of hyperbaric oxygen services, b) infusion therapy services, c) cardiac rehabilitation services, or d) diagnostic sleep studies. They do not meet the definition of a CORF services and/or they do not relate to the rehabilitation plan of treatment.  These services, and other services not specifically listed as CORF services, may be covered under another Medicare benefit category, such as physician services, incident -to physician services, and diagnostic services.  Physical therapy, occupational therapy, and speech- language pathology services may be furnished in the patients home, as CORF services, when payment for these therapy services is  not otherwise made under the Medicare home health benefit.  However, since the CORF premise is the primary location for furnishing these services, it is expected that a clear majority of the physical therapy, occupational therapy and speech -language pathology services delivered will be provided on the CORF premises for all CORF patients.   In addition to the above noted services, which may be provided in the home, a single home environment evaluation visit is a covered CORF service if it is included in the rehabilitation plan of treatment.  The patient must be present during the home environment evaluation that is performed by the physical therapist, occupational therapist, or speech- language pathologist, as appropriate.  The patients presence is necessary to assess the patients current or future ability to function safely in the home environment and to determine the potential impact the home situation will have on the patients rehabilitation goals.   Services provided under the incident to benefit may not be recognized as CORF services.  Services furnished by CORF personnel, including registered nurses, physical therapists, occupational therapists, speech- language pathologists, respiratory therapists, social workers and psychologists are not considered as  furnished incident -to physician services.   The CORF physician must be present in the facility for a sufficient time to ensure that CORF services are provided in accordance with accepted principles of medical practice. All CORF services must be provided wi thin acceptable professional standards and practice (42CFR485.70, and 410.100).   20 - Required and Optional CORF Services (Rev. 1, 10- 01-03) A3-3180, CORF -250  20.1 - Required Services  (Rev.  255, Issued: 01- 25-19, Effective: 01-  01- 19, Implementation: 02- 26-19)  Section 1861(cc) of the Act defines a CORF as a facility that is primarily engaged in providing outpatient rehabilitation to the injured and disabled or to patients recovering from illness.  The CORF must provide the following core CORF services : a) CORF physicians services, b) physical therapy services, and c) social and/or psychological services.  Physical therapy services should comprise a clear majority of the total CORF services provided when the CORF offers the three core CORF services.  A  physician must certify, as a condition of payment, that all CORF services are required because the individual needs skilled rehabilitation services.  Skilled rehabilitation services are defined as services requiring the skills of physical therapists, speech -language pathologists or occupational therapists. In addition, respiratory therapists are recognized to provide skilled respiratory therapy services only under the CORF benefit.   A CORF is recognized as a provider of rehabilitation services.  It is paid  under the physician fee schedule for all CORF services and items except for CORF physician services (which are administrative in nature), drugs and biologicals  and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) .  To participate i n Medicare, a CORF must furnish at least the following:    CORF  physicians services -  includes  professional services performed by a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs se rvices.  These services are administrative in nature, such as consultation with, and medical supervision of, CORF qualified personnel, patient case review conferences, utilization review, and review of the rehabilitation plan of treatment, as  appropriate .  The physician must ensure that CORF services are provided in accordance with accepted principles of medical practice, medical direction and medical supervision.  Subsequent to completing a 1-year hospital internship, the physician must have completed at l east 1 -year of training in the medical management of patients requiring rehabilitative services (42CFR485.70) or at least 1 year of full -time or part- time experience in a rehabilitation setting providing physician services similar to those required in a rehabilitation facility.  A physician who specializes only in pulmonary rehabilitation does not meet these requirements as he/she is not likely to have the experience needed to medically manage patients that need physical therapy, occupational therapy and sp eech-language pathology services.  Diagnostic or therapeutic services provided to a CORF patient by the CORF physician or other physician are not CORF physician services.  Such services are separately payable to the physician and not the CORF under the phy sician fee schedule at the non -facility payment amount.  These services should be billed as if they were provided in the physicians office.  (See 42CFR410.100(a) and section 40.1.)    Physical therapy services -  include testing, measurement, assessment and treatment of the function, or dysfunction, of the neuromuscular, musculoskeletal, cardiovascular and respiratory system, and establishment of a maintenance therapy program for an individual whose restoration potential has been reached  (See 42CFR410.100(b) and section 40.2); and    Social and/or psychological services  are covered only if the patients physician or the CORF physician establishes that the services directly relate to the patients rehabilitation plan of treatment and are needed to achieve the g oals in the rehabilitation plan of treatment.  Social and/or psychological services include only those services that address the patients response and adjustment to the rehabilitation treatment plan; rate of improvement and progress towards the rehabilita tion goals, or other services as they directly relate to the physical therapy, occupational therapy, speech- language pathology, or respiratory therapy plan of treatment being provided to the patient.  CORF social and/or psychological services do not include services for mental health diagnoses  (See 42CFR410.100(h) and section 40.7.)   To receive Medicare payment for covered services, the CORF must have adequate space and equipment necessary for any of the services provided.  Additionally, in order to accept  a patient,  the CORF must be able to provide all of the services required by the patient, as established in the rehabilitation plan of treatment.  If the CORF does not have the necessary qualified personnel to provide the service(s), it must arrange for the service(s) to be provided at the CORF, as needed.   Functional reporting is required on claims for CORF physical therapy, occupational therapy, and speech -language pathology services by section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012.  (See 42CFR410.105 and 42CFR410.59, 60, and 62.)   NOTE : Functional reporting and its associated documentation requirements are no longer applicable for claims or medical records for dates of service on and after January 1, 2019.  See  the NOTE  at the beginning of subsection F in Section 30 below for more information.    The CORF services are subject to the Medicare Part B deductible and coinsurance provisions. T he CORF may bill the beneficiary only for the unmet portion of the deductible and 20 percent of the fee schedule amount for covered services.   20.2 - Optional CORF Services  (Rev. 111, Issued: 09- 25-09; Effective Date: 07 -07-08; Implementation Date: 10 -26-09)  In addition to the three required core CORF services, the CORF may furnish any of the other covered and medically necessary items and services listed in 20.2 .  These optional services must directly relate to, and be consistent with, the rehabilitation plan of treatment, and must be necessa ry to achieve the patients rehabilitation goals.  When a CORF provides occupational therapy, speech- language pathology and/or respiratory therapy services in addition to the required physical therapy services, the physical therapy services shall represent  the predominate rehabilitation service provided.  For discussion of payment rules see section 30.1.  The CORF may provide any or all of the following rehabilitation services:   Occupational therapy -  services include assessment of an individuals level of independent functioning, selection and teaching of task- oriented therapeutic activities to restore sensory -integrative functions, teaching of compensatory techniques to permit an individual with a physical or cognitive impairment or limitation to engage in  daily activities (See 42CFR410.100(c) and section 40.3);    Speech -  Language pathology -  services for the diagnosis and treatment of speech and language disorders that create difficulties in communication or dysphagia (swallowing difficulties).  (See 42CFR410.100(d) and section 40.4);    Respiratory therapy - services includes only those services that can be appropriately provided to CORF patients by a qualified respiratory therapist (42CFR485.70(j)) under a physician- established respiratory therapy plan  of treatment in accordance with current medical and clinical standards  (See 42CFR410.100(e) and section 40.5);    Prosthetic and orthotic devices -  includes testing, fitting, or training in the use of such devices  (See 42CFR410.100(f) and (g) and section 40.6);    Nursing  includes nursing services (e.g., teaching self catheterization) that directly relate to and are specified in the rehabilitation plan of treatment, are necessary for the attainment of the rehabilit ation goals and are  provided by a registered nurse as defined in 42CFR485.70(h).  (See 42CFR410.100(i) and section 40.8);