(Medicare Benefit Policy Manual)

Payment for covered durable medical equipment, orthotic and prosthetic (DMEPOS) devices and supplies provided by a CORF is based upon: the lesser of 80 percent of actual charges or the payment amount established under the DMEPOS fee schedule; or, the single payment amount established under the DMEPOS competitive bidding program, provided that payment for such an item is not included in the payment amount for other CORF services.   If there is no fee schedule amount for a covered CORF item or service, payment should be based on the lesser of 80 percent of the actual charge for the service provided or an amount determined by the local Medicare contractor.   The following conditions apply to CORF physical therapy, occupational therapy, and speech -language pathology services;    Claims must contain the required functional reporting.  (Reference: Sections 42 CFR 410.105.)  Refer to Pub. 100- 04, Medicare Claims Processing Manual, chapter 5, section 10.6.  NOTE : Functional reporting and documentation requirements are no longer applicable for claims for dates of service on and after January 1, 2019.  For more information, refer to subsection F in section 30 above.     The functional reporting on claims must be consistent with the functional limitations identified as part of the patients therapy plan of care and expressed as part of the patients therapy goals; effective for claims with dates of service on and after January, 1, 2013.  (Reference: 42 CFR 410.105.)  See Pub. 100- 04, Medicare Claims Pro cessing Manual, chapter 5, section 10.6.  NOTE : Functional reporting and documentation requirements are no longer applicable for claims for dates of service on and after January 1, 2019.  For more information, refer to subsection F in section 30 above.      The National Provider Identifier (NPI) of the certifying physician identified for a CORF physical therapy, occupational therapy, and speech -language pathology plan of treatment must be included on the therapy claim.  This requirement is effective for clai ms with dates of service on or  after October 1, 2012.  (See Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.3.)    Payment for CORF social and/or psychological services is made under the physician fee schedule only for HCPCS code G0409, as appropriate, and only when billed using revenue codes 0560, 0569, 0910, 0911, 0914 and 0919.  Payment for CORF respiratory therapy services is made under the physician fee schedule when provided by a respiratory therapist as defined at 42CFR485.70(j ) and, only to the extent that these services support or are an adjunct to the rehabilitation plan of treatment, when billed using revenue codes 0410, 0412 and 0419.  Separate payment is not made for diagnostic tests or for services related to physiologic monitoring services which are bundled into other respiratory therapy services appropriately performed by a respiratory therapist, such as HCPCS codes G0237, G0238 and G0239.  Payment for CORF nursing services is made under the physician fee schedule only w hen provided by a registered nurse as defined at 42CFR485.70(h) for nursing services only to the extent that these services support or are an adjunct to the rehabilitation plan of treatment.  In addition, payment for CORF nursing services is made only when provided by a registered nurse.  HCPCS code G0128 is used to bill for these services and only with revenue codes 0550 and 0559.  For specific payment requirements for CORF items and services see Pub. 100- 04, Medicare Claims Processing Manual, Chapter 5, P art B Outpatient Rehabilitation and CORF/OPT Services.   40 - Specific CORF Services  (Rev. 1, 10- 01-03) A3-3183, CORF -253  40.1 - Physicians Services  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  Certain administrative services provided by a qualified physician, as defined at 42CFR485.70(a), associated with the CORF are considered CORF physician services, which are not billable by the CORF.  These services include administrative services provided b y the physician associated with the CORF, such as:    consultation with and medical supervision of nonphysician staff,   team conferences,   case reviews, and   other facility medical and administration activities necessary to the provision of skilled rehabilitation services, and   Other services that directly relate to the rehabilitation plan of treatment.   Examinations for the purpose of establishing and reviewing the rehabilitation plan of care that do not result in a billable service would also represent CORF physician services.   Physicians diagnostic and therapeutic services (e.g., evaluation and management services, debridement, electrocardiography (ECG)), furnished to an individual CORF patient are not CORF physicians services.  They are physician services  and are billable to the Medicare contractor, as appropriate.  The physician, not the CORF, bills for and is paid by Medicare for these services.  The physician claim must be clearly annotated to show the CORF as the place of treatment, which is paid at the nonfacility physician fee schedule rate.   40.2 - Physical Therapy Services  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  A qualified physical therapist, as defined at 42CFR485.70(e), has the knowledge, training , and experience required to evaluate and reevaluate, as appropriate, a patient's level of function, determine whether a physical therapy program could reasonably be expected to improve, restore, or compensate for lost function, and recommend to the physic ian a plan of treatment.  The skills of a qualified physical therapist are required to evaluate and reevaluate the patient's level of function and to develop, in consultation with the physician as appropriate, the physical therapy plan of treatment.  A qua lified physical therapist assistant (PTA), as defined at 42CFR485.70(e), functioning under the supervision of the qualified physical therapist may carry out certain procedures of the physical therapy plan of treatment, in accordance with applicable State l aws.  Only the physical therapist, not the PTA can conduct the discharge visit as this visit is viewed as the final assessment of the patients progress toward attaining the goals of the physical therapy plan of treatment.   Physical therapy is not required  to effect improvement or restoration of function when a patient suffers a temporary loss or reduction of function (e.g., temporary weakness resulting from prolonged bed rest after major abdominal surgery) that can reasonably be expected to improve spontaneously as the patient gradually resumes normal activities.  Accordingly, physical therapy furnished in such situations is not considered reasonable and necessary for the treatment of the individual's illness or injury and the services are excluded from coverage.   All therapy coverage and documentation guidelines (except for development of plan of treatment) noted in Pub. 100- 02, Benefit Policy Manual, chapter 15, sections 220-220.3(E) apply to the CORF setting.   NOTE : Supervision of CORF physical therapy se rvices requires that the physical therapist  must be on the premises of the CORF or must be available to the physical therapy assistant through direct telecommunications for consultation and assistance during the CORFs operating hours. (See 42CFR485.58(d)( 6)).  40.3 - Occupational Therapy Services  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  Occupational therapy is a medically prescribed treatment to improve or restore functions that have been impaired by illness  or injury or, when function has been permanently lost or reduced by illness or injury, to improve the individual's ability to perform those tasks required for independent functioning.  Occupational therapy services are covered CORF services if physical th erapy services are the predominate rehabilitation services provided in the CORF.  A qualified occupational therapist, as defined at 42CFR485.70(c), has the knowledge, training, and experience required to evaluate and reevaluate a patient's level of functio n, determine whether an occupational therapy program could reasonably be expected to improve, restore, or compensate for lost function, and recommend to the physician a plan of treatment.  The skills of a qualified occupational therapist are required to ev aluate and reevaluate the patient's level of function and to develop, in consultation with the physician as appropriate, the occupational therapy plan of treatment.  A qualified occupational therapy assistant, as defined at 42CFR485.70(c), functioning unde r the supervision of the qualified occupational therapist may also carry out various aspects, as appropriate, of the occupational therapy plan of treatment, in accordance with applicable State laws.  Occupational therapist assistants are not allowed to con duct the discharge visit as this visit is viewed as the final assessment of the patients progress toward attaining the goals of the occupational therapy plan of treatment.   NOTE :  Supervision of CORF occupational therapy services requires that the occupational therapist  either must be on the premises of the CORF or must be available to the occupational therapy assistant through direct telecommunications for consultation and assistance during the CORFs operating hours. (See 42CFR485.58(d)(6)).   40.4  Speech -Language Pathology Services  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  Services related to congenital speech difficulties, such as stuttering or lisping, are not covered.   A qualified speech -language pathologist , as defined at 42CFR485.70(m), has the knowledge, training, and experience required to evaluate and reevaluate, as appropriate, a patient's level of function, determine whether a speech -language program could reasonably be expected to improve,  restore, or compensate for lost function, and to recommend to the physician a plan of treatment.  A qualified speech- language pathologist must evaluate and reevaluate the patients level of function to develop , in consultation with the physician as appropriate,  the speech -language pathology plan of treatment.  Speech -language pathology  therapy services are covered CORF services if physical therapy services are the predominate rehabilitation services provided in the CORF .  40.5 - Respiratory Therapy Service s (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  A respiratory therapy plan of treatment is wholly established and signed by the referring physician before the respiratory therapist initiates the actual treatment.   A. Definition   Respiratory therapy services include only those services that can be appropriately provided to CORF patients by a qualified respiratory therapist , as defined at 42CFR485.70(j), under a physician -established respiratory therapy plan of treatment.  The facility physician must be present in the facility for a sufficient time to provide, in accordance with accepted principles of medical practice, medical  direction, medical care services and consultation.  Respiratory therapy services include the physiological monitoring necessary to furnish these services.  Payment for these services is bundled into the payment for respiratory therapy services and is not payable separately.  Diagnostic and other medical services provided in the CORF setting are not considered CORF services, and therefore may not be included in a respiratory therapy plan of treatment because these are covered under separate benefit categori es.  The respiratory therapist assesses the patient to determine the appropriateness of pursed lip breathing activity and may check the patients oxygen saturation level (via pulse oximetry).  If appropriate, the respiratory therapist then provides the ini tial training in order to ensure that the patient can accurately perform the activity.  The respiratory therapist may again check the patients oxygen saturation level, or perform peak respiratory flow, or check other respiratory parameters. These types of  services are considered  physiological monitoring and are bundled into the payment for  HCPCS codes  G0237, G0238 and G0239.  P hysiological monitoring also includes the provision of a 6 -minute walk test that is typically conducted before the start of the p atients respiratory therapy activities.  The time to provide this walk test assessment is included as part of the HCPCS code G0238.  When provided as part of a CORF respiratory therapy plan of treatment, payment for these monitoring activities is bundle d into the payment for other services provided by the respiratory therapist, such as the three respiratory therapy specific G -codes.   B. Guidelines for Applying Coverage Criteria