Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A56566)

CMS National Coverage PolicyLanguage quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.Unless otherwise specified,italicizedtext represents quotation from one or more of the following CMS sources:Title XVIII of the Social Security Act (SSA):Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners.Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.Section 1862(a)(20) excludes payment for PT or OT services furnished incident to the physician by personnel that do not meet the qualifications that apply to therapists, except licensing.Code of Federal Regulations42 CFR, Sections 410.59 and 410.61 describe outpatient occupational therapy services and the plan of treatment for outpatient rehabilitation services, respectively.42 CFR, Sections 410.60 and 410.61 describe outpatient physical therapy services and the plan of treatment for outpatient rehabilitation services, respectively.42 CFR, Sections 410.74, 410.75, 410.76, and 419.22 define the services of non-physician practitioners.42 CFR, Sections 424.24 and 424.27 describe therapy certification and plan requirements.42 CFR, Sections 424.4, 482.56, 484 and 485.705 define therapy personnel qualification requirements.42 CFR, Section 486 describes coverage for services rendered by physical therapists in independent practice.Federal RegisterFederal Register, Vol. 72, No. 227, November 27, 2007, pages 66328-66333 and 66397-66408, and the correction notice for this rule, published in the Federal Register on January 15, 2008, pages 2431-2433, addresses personnel qualification standards for therapy services and certification requirements.Federal Register, July 22, 2002, Decision Memo for Neuromuscular Electrical Stimulation (NMES) for Spinal Cord Injury (CAG 00153R), at:http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=55&CMS Publications:CMS Publication 100-02,Medicare Benefit Policy Manual, Chapter 15:220 through 230 Coverage and documentation requirements for physical and occupational therapy services.CMS Publication 100-03,Medicare National Coverage Decisions (NCD) Manual, (multiple sections):provides coverage information on several specific types of therapy services. See body of LCD for individual references.CMS Publication 100-04,Claims Processing Manual, Chapter 5:10.2 Financial limitation for therapy services (therapy cap).CMS Publication 100-04,Claims Processing Manual, Chapter 5:20-100 HCPCS coding and therapy billing requirements.CMS Publication 100-04,Claims Processing Manual, Chapter 20:1-10 Orthotics billing.CMS, 11 Part B Billing Scenarios for PTs and OTs, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp#TopOfPageCommunication from CMS that the Contractor LCD is not required to include the V57.1-V57.89 ICD-9-CM codes.CMS Transmittal No. 4149, Publication 100-04,Medicare Claims Processing Manual, October 23, 2018, removes Functional Reporting requirements and edits for outpatient therapy services.CMS Transmittal No. 179, Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius, Change request #8458, January 14, 2014, provides clarification that coverage of skilled nursing and skilled therapy services does not turn on the presence or absence of a beneficiarys potential for improvement, but rather on the beneficiarys need for skilled care.Article TextThis article contains coding guidelines that complement the Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services (L33631).Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.The diagnosis code(s) must best describe the patient's condition for which the service was performed.A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.Unless otherwise specified, italicized text within this article represents quotation from CMS sources.CMS National Coverage provisions:Services that do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation, do not constitute (covered) therapy services for Medicare purposes.MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.In the case of rehabilitative therapy, improvement is evidenced by successive objective measurements whenever possible. If an individuals expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities (CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 220.2(C)).In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patients functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel.Skilled TherapyA service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.Skilled therapy services may be necessary to improve a patients current condition, to maintain the patients current condition, or to prevent or slow further deterioration of the patients condition.Rehabilitative therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in each state) are necessary to safely and effectively furnish a recognized therapy service, whose goal is improvement of an impairment or functional limitation.Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiarys need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patients clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.While a beneficiarys particular medical condition is a valid factor in deciding if skilled (rehabilitative or maintenance)therapy services are needed, a beneficiarys diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the service(s) can be carried out by non-skilled personnelTherapy StudentsQualified professionals may serve as clinical instructors for therapy students within their scope of practice. Physical therapist assistants and occupational therapy assistants may only serve as clinical instructors for physical therapist assistant students and occupational therapy assistant students, respectively, when performed under the direction and supervision of the licensed physical or occupational therapist (in states where licensure applies). Services performed by a student (therapy student or therapy assistant student) are not reimbursed, even if provided under line of sight supervision of the therapist. However, the services of a qualified professional are covered, even when a student is participating in the care. To be covered when the student is participating, the qualified professional must be present in the room and must:direct the service, making the skilled judgment and assessment, and assume responsibility for the treatment;not be engaged in treating another patient or doing other tasks at the same time (such as documentation); AND mustsign all documentation appropriately. A student may also sign the documentation, but it is not necessary since the Part B payment is for the qualified professionals service, not for the students services.Supervision LevelsSupervision levels for outpatient therapy services depend on the setting where they are provided. Direct supervision (in the office suite) by a physician/NPP is required for therapists and qualified auxiliary personnel when therapy services are provided incident to the services of a physician/NPP. Also, direct supervision by a physical therapist (for PTAs) or occupational therapist (for OTAs) is required when assistants provide therapy services in the private practice setting or in the office of a physician/NPP. General supervision (the supervising therapist is available but not necessarily on the premises) is required by a physical therapist (for PTAs) or occupational therapist (for OTAs) when therapy services are provided in any other setting.Private Practice Therapy ServicesTo qualify as a private practice, each individual must be enrolled as a private practitioner and employed in one of the following practice types:unincorporated solo practice, partnership, or group practice;physician/NPP group or groups that are not professional corporations, if allowed by state and local law;physical or occupational therapist employed by physician/NPP group practices (PTPP, OTPP), if state and local law permits this employee relationship.Private practice also includes therapists who are practicing therapy as employees of another supplier, of a professional corporation or other incorporated therapy practice. Private practice does not include individuals when they are working as employees of an institutional provider.Services should be furnished in the therapists or groups office or in the patients home. The office is defined as the location(s) where the practice is operated during the hours that the therapist engages in the practice at that location. If the services are furnished in a private practice office space, that space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.Therapy Provided by Physicians and Physician EmployeesThe services of PTAs and OTAs also may not be billed incident to a physicians/NPPs service. However, if a PT and PTA (or an OT and OTA) are both employed in a physicians office, the services of the PTA, when directly supervised by the PT or the services of the OTA, when directly supervised by the OT may be billed by the physician group as PT or OT services using the PIN/NPI of the enrolled PT (or OT). (See Section 230.4 for private practice rules on billing services performed in a physicians office.) If the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA billed incident to the physicians service, because they do not meet the qualification standards in 42CFR484.4.Coding Information and Documentation Requirements for Specific Services:CPT 97161-97163  Physical therapy evaluation CPT 97165-97167  Occupational therapy evaluationWhen an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP. The goal, frequency, and duration of treatment are implied in the diagnosis and one-time 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. Therefore, when evaluation is the only service, a referral/order and evaluation are the only required documentation. If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient.For initial evaluations, PTs shall use codes 97161-97163 and OTs shall use codes 97165-97167. Physicians and other qualified non-physician providers should use the evaluation and management codes 99201-99350 for evaluations.Consider the following points when billing for an evaluation.