(Medicare Claims Processing Manual)

The codes that are al lowed 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 indic ated by the discipline in that column.  Some codes may be billed by one discipline (e.g., PT) and not by others (e.g., OT or SLP).   When physicians/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 PT, OT or SLP 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 use d, but the number of units billed must not exceed the number of units indicated in the chart below per patient, per provider/supplier, per day.   NOTE:  As of April 1, 2017, the chart below uses the CPT Consumer Friendly Code Descriptions which are intended only to assist the reader in identifying the service related to the CPT/HCPCS code.  The reader is reminded that these descriptions cannot be used in place of the CPT long descriptions which officially define each of the services.   The table below no lon ger contains a column noting whether a code is timed or untimed as this notation is not relevant to the number of units allowed per code on claims for the listed therapy services. We note that the official long descriptors for the CPT codes can be found in the latest CPT code book.  CPT/  HCPCS  Code  CPT Consumer Friendly Code Descriptions and PT  Allowed Units  OT  Allowed Units  SLP  Allowed Units  Physician/ NPP Not    Claim Line Outlier/Edit Details  Under Therapy POC  92521  Evaluation of speech fluency  0 0 1 NA 92522  Evaluation of speech sound production  0 0 1 NA 92523  Evaluation of speech sound production with evaluation of language comprehension and expression  0 0 1 NA 92524  Behavioral and qualitative analysis of voice and resonance  0 0 1 NA 92597  Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech  0 0 1 NA 92607  Evaluation of patient with prescription of speech-generating and alternative communication device  0 0 1 NA 92611  Fluoroscopic and video recorded motion evaluation of swallowing function  0 1 1 1 92612  Evaluation and recording of swallowing using an endoscope Evaluation and recording of swallowing using an endoscope  0 1 1 1 92614  Evaluation and recording of voice box sensory function using an endoscope  0 1 1 1 92616  Evaluation and recording of swallowing and voice box sensory function using an endoscope  0 1 1 1 95833  Manual muscle testing of whole body  1 1 0 1 95834  Manual muscle testing of whole body including hands  1 1 0 1 96110  Developmental screening  1 1 1 1   96111  Developmental testing  1 1 1 1 97161  Evaluation of physical therapy, typically 20 minutes  1 0 0 NA 97162  Evaluation of physical therapy, typically 30 minutes  1 0 0 NA 97163  Evaluation of physical therapy, typically 45 minutes   1 0 0 NA 97164  Re-evaluation of physical therapy, typically 20 minutes  1 0 0 NA 97165  Evaluation of occupational therapy, typically 30 minutes  0 1 0 NA 97166  Evaluation of occupational therapy, typically 45 minutes  0 1 0 NA 97167  Evaluation of occupational therapy, typically 60 minutes  0 1 0 NA 97168  Re-evaluation of occupational therapy established plan of care, typically 30 minutes  0 1 0 NA  20.3 -  Determining What Time Counts Towards 15- Minute Timed Codes -  All Claims  (Rev. 1, 10- 01-03)  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 treat ment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.   The time counted is the time the patient is treated.  For example, if gait training in a patient with a recent stroke requires both a therapist and an assistant , or even two therapists, to manage in the parallel bars, each 15 minutes the patient is being treated can count as only one unit of code 97116.  The time the patient spends not being treated because of the need for toileting or resting should not be bille d.  In addition, the time   spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time.   20.4 -  Coding Guidance for Certain CPT Codes -  All Claims  (Rev. 3475, Issued: 03- 04-16, Effective: 06- 06-16, Implementation: 06 -06-16)  The following provides guidance about the use of codes 96105, 97026, 97150, 97545, 97546, and G0128.    CPT Codes 96105, 97545, and 97546.  Providers report code 96105, assessment of aphasia with interpretation and report in 1-hour units.  This code represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination.  If this formal assessment is performed during treatment, it is typically performed only once during treatment and its medical necessity should be documented.  If the test is repeated during treatment, the medical necessity of the repeat administration of the test must also be documented.  It is common practice for regular assessment of a patients progress in therapy to be documented in the chart, and this may be done using test items taken from the formal examinations.  This is considered to be part of the treatment and should not be billed as 96105 unless a full, formal assessment is completed.   Other timed physical medicine cod es are 97545 and 97546.  The interval for code 97545 is 2 hours and for code 97546, 1 hour.  These are specialized codes to be used in the context of rehabilitating a worker to return to a job.  The expectation is that the entire time period specified in the codes 97545 or 97546 would be the treatment period, since a shorter period of treatment could be coded with another code such as codes 97110, 97112, or 97537.  (Codes 97545 and 97546 were developed for reporting services to persons in the workers compensation program, thus CMS does not expect to see them reported for Medicare patients except under very unusual circumstances.  Further, CMS would not expect to see code 97546 without also seeing code 97545 on the same claim.  Code 97546, when used, is use d in conjunction with 97545.)    CPT Code 97026  Effective for services performed on or after October 24, 2006, the Centers for Medicare & Medicaid Services announce a NCD stating the use of infrared and/or near -infrared light and/or heat, including monochromatic infrared energy (MIRE), is non -covered for the treatment, including symptoms such as pain arising from these conditions, of diabetic and/or non- diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Me dicare beneficiaries.  Further coverage guidelines can be found in the National Coverage Determination Manual (Pub. 100- 03), section 270.6.  Contractors shall deny claims with CPT 97026 (infrared therapy incident to or as a PT/OT benefit) and HCPCS E0221 or A4639, if the claim contains any of the following diagnosis codes:     ICD- 9-CM  250.60 -  250.63  354.4, 354.5, 354.9  355.1 -  355.4  355.6 -  355.9  356.0, 356.2- 356.4, 356.8- 356.9  357.0 -  357.7  674.10, 674.12, 674.14, 674.20, 674.22, 674.24  707.00 - 707.07, 707.09- 707.15, 707.19  870.0 -  879.9  880.00 -  887.7  890.0 -  897.7  998.31 -  998.32  ICD- 10-CM  See Addendum A Chapter 5, Section 20.4 (at end of this chapter) for the list of ICD 10 -CM diagnosis codes that require denial with the above HCPCD codes.   The contractor shall use the following remittance advice messages and associated codes when rejecting/denying claims under this policy.  This CARC/RARC combination is compliant with CAQH CORE Business Scenario Three.   Group Code: CO  CARC: 50  RARC: N/A  MSN: 21.11  Advanced Beneficiary Notice (ABN):   Physicians, physical therapists, occupational therapists, outpatient r ehabilitation facilities (ORFs), comprehensive outpatient rehabilitation facilities (CORFs), home health   agencies (HHA), and hospital outpatient departments are liable if the service is performed, unless the beneficiary signs an ABN.   Similarly, DME suppliers and HHA are liable for the devices when they are supplied, unless the beneficiary signs an ABN.   20.5 - CORF/OPT Edit for Billing Inappropriate Supplies  (Rev. 319, Issued: 10- 22-04, Effective: 07- 01-01, Implementation: 04- 04-05)  Supplies furnished by CORFs/OPTs are considered part of the practice expense. Under the Medicare Physician Fee Schedule (MPFS) these expenses are already taken into account in the practice expense relative values.  Therefore, CORFs/OPTs should not bill for the supplies they fur nish except for the splint and cast, level II HCPCS Q codes associated with the level I HCPCS in the 29000 series.  The shared system maintainer will return to CORFs/OPTs any claims that they receive that contain a supply revenue code 270 without the splint and cast Level II HCPCS Q codes and the related Level I applicable HCPCS codes in the 29000 series.   The appropriate Level II HCPCS Q codes to be used are Q4001 thru Q4049.  The appropriate Level I HCPCS codes associated with the Level II HCPCS Q  codes are 29000 thru 29085; 29105 thru 29131; and 29305 thru 29515.  30 - Special Claims Processing Rules for Outpatient Rehabilitation Claims - Form CMS -1500 (Rev. 1, 10- 01-03)  Rules for completing a Form CMS -1500 and electronic formats are in Chapter 26.  Instructions in 10.1, 20.1, 20.2, 20.3 and 20.4 above also apply.   30.1 -  Determining Payment Amounts  (Rev. 1, 10- 01-03)  A/B MACs (B)  use the MPFS to determine payment for outpatient rehabilitation services.  Payment rules are the same as those for other services paid on the MPFS.   Assignment is mandatory.   See chapter 23, for a description of the MPFS.  30.2 -  Applicable A/B MAC (B)  CWF Type of Service Codes  (Rev. 1, 10- 01-03)  The A/B MAC (B) assigns the type of service code before submitting the claim record to CWF.     U = Occupational therapy  W= Physical therapy   40 - Special Claims Processing Rules for Institutional Outpatient Rehabilitation Claims  (Rev. 1921, Issued: 02- 19-10, Effective: 04- 01-10, Implementation: 04- 05-10)