(Medicare Benefit Policy Manual)

Covered therapy services are furnished by providers, by others under arrangements with and under the supervision of providers, or furnished by suppliers (e.g., physicians, NPP, enrolled therapists), who meet the requirements in Medicare manuals for therapy services.    Where a prospective payment system (PPS) applies, therapy services are paid when services conform to the requirements of that PPS.  Reimbursement for therapy provided to Part A inpatients of hospitals or residents of SNFs in covered stays is included in the respective PPS rates.    Payment for therapy provided by an HHA under a plan of treatment is included in the home health PPS rate.  Therapy may be billed by an HHA on bill type 34x if there are no home health services billed under a home health plan of care at the same time (e.g.,  the patient is not homebound), and there is a valid therapy plan of treatment.    In addition to the requirements described in this chapter, the services must be furnished in accordance with health and safety requirements set forth in regulations at 42CFR484, and 42CFR485.    When therapy services may be furnished appropriately in a community pool by a clinician in a physical therapist or occupational therapist private practice, physician office, outpatient hospital, or outpatient SNF, the practice/office or provider shall rent  or lease the pool, or a specific portion of the pool.  The use of that part of the pool during specified times shall be restricted to the patients of that practice or provider.  The written agreement to rent or lease the pool shall be available for review  on request.  When part of the pool is rented or leased, 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.  Other providers, including re habilitation agencies (previously referred to as OPTs and ORFs) and CORFs, are subject to the requirements outlined in the respective State Operations Manual regarding rented or leased community pools.   220.1 - Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech -Language Pathology Services  (Rev.  255, Issued: 01- 25-19, Effective: 01 - 01- 19, Implementation: 02- 26-19)  Reference:  42CFR424.24  Refer to  230.4 for physical therapist/occupational therapist in private practice rules.   Coverage rules for specific services are in Pub. 100- 03, Medicare National Coverage Determinations Manual.   Other payment rules are found in Pub. 100- 04, Medicare Claims Processing Manual, chapter 5 .  Since the outpatient therapy benefit under Part B provides coverage only of therapy services, payment can be made only for those services that constitute therapy.  In cases where there is doubt about whether a service is therapy, the contractors local coverage determination (LCD) shall prevail.   In order for a service to be covered, it must have a benefit category in the statute, it must not be excluded and it must be reasonable and necessary.  Therapy services are a benefit under 1861 of the Act.  Consult Pub. 100- 08, chapter 13, 13.5.1 for full descriptions of a reasonable and necessary service.   Outpatient therapy services furnished to a beneficiary by a provider or supplier are payable only when furnished in accordance with certain conditions.  The following conditions apply.   Services are or were required because the individual needed therapy services (see 42CFR424.24(c),220.1.3);    A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP* (see 42CFR424.24(c), 220.1.2 );   Services are or were furnished while the individual is or was under the care of a physician* (see 42CFR424.24(c), 220.1.1);    In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above three conditions are met (42 CFR 424.24(c)).  Certification is required for coverage and payment of a therapy claim.    Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care.  This requirement is effective for claims with dates of service on or af ter October 1, 2012.  (See Pub. 100- 04, Medicare Claims Processing Manual, chapter 5, section 10.3.)     Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the required functional reporting.  (See 42CFR410.59, 60, and 62), Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6.)  NOTE : The applicable regulatory provisions were removed through the CY 2019 PFS final rule, CMS-1693-F.  Functional reporting requirements are no longer applicable for claims for dates of service on and after January 1, 2019. See the NOTE  at the beginning of Section 220.4 for more information.    The patient functional limitations(s) reported on claims, as part of the functional reporting, must be consistent with the functional limitations identified as part of the therapy plan of care and expressed as part of the patients long term goals*  (see 42CFR410.61, 42CFR410.105, Pub. 100-04, Medicare Claims Processing Manual, chapter 5, section 10.6.)  NOTE : The applicable regulatory provisions were removed through the CY 2019 PFS final rule, CMS-1693-F.  Functional reporting and its documentation requirements are no longer applicable for claims or medical records for dates of service on and after January 1, 2019.      220.1.1 - Care of a Physician/Nonphysician Practitioner (NPP)  (Rev. 179, Issued: 01-14-14, Effective: 01-07-14, Implementation: 01-07-14)  Although there is no Medicare requirement for an order, when documented in the medical record,  an order provides evidence that the patient both needs therapy services and is under the care of a physician.  The certification requirements are met when the physician certifies the plan of care.  If the signed order includes a plan of care (see essential  requirements of plan in 220.1.2), no further certification of the plan is required.  Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the pla n.  (The CORF services benefit does not recognize an NPP for orders and certification.)  220.1.2 - Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech -Language Pathology Services  (Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)  Reference: 42CFR 410.61 and 410.105(c) (for CORFs)  A.  Establishing the plan (See 220.1.3 for certifying the plan.)  The services must relate directly and specifically to a written treatment plan as described in this chapter.  The plan, (also known as a plan of care or plan of treatment) must be established before treatment is begun.  The plan is established when it is developed (e.g., written or dictated).   The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established must be recorded with the plan.  Establishing the plan, which is described below, is not the same as certifying the plan, which is described in 220.1.1 and 220.1.3  Outpatient therapy services shall be furnished under a plan established by:   A physician/NPP (consultation with the treating physical therapist, occupational therapist, or speech- language pathologist is recommended.  Only a physician may establish a plan of care in a CORF;    The physical therapist who will provide the physical therapy services;    The occupational therapist who will provide the occupational therapy services; or    The speech -language pathologist who will provide the speech- language pathology services.   The plan may be entered into the patients therapy record either by the person who established the plan or by the providers or suppliers staff when they make a written record of that persons oral orders before treatment is begun.  Treatment under a Plan.  The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.  It is appropriate that treatment begins when a plan is established.  Therapy may be initiated by qualified professionals or qualified personnel based on a dictated plan.  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 pla n.  Payment for services provided before a plan is established may be denied.   Two Plans.  It is acceptable to treat under two separate plans of care when different physicians/NPPs refer a patient for different conditions.  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.  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 pos sible to make clear that the goals for each plan are addressed.  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, but shall not be r equired by contractors.  B.  Contents of Plan (See 220.1.3 for certifying the plan.)   The plan of care shall contain, at minimum, the following information as required by regulation (42CFR424.24, 410.61, and 410.105(c) (for CORFs)).  (See 220.3 for further documentation requirements):    Diagnoses;    Long term treatment goals; and   Type, amount, duration and frequency of therapy services.   The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan.  The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable out come with the appropriate resources.   Long term treatment goals should be developed for the entire episode of care in the current setting.  When the episode is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode t hat is being certified.  Goals should be measurable and pertain to identified functional impairments.  Therapists typically also establish short term goals, such as goals for a week or month of therapy, to help track progress toward the goal for the episode of care.  If the expected episode of care is short, for example therapy is expected to be completed in 4 to 6 treatment days, the long term and short term goals may be the same.  In other instances measurable goals may not be achievable, such as when treatment in a particular setting is unexpectedly cut short (such as when care is transferred to another therapy provider) or when the beneficiary suffers an exacerbation of his/her existing condition terminating the current episode; documentation should stat e the clinical reasons progress cannot be shown.  The functional impairments identified and expressed in the long term treatment goals must be consistent with those used in the claims -based functional reporting, using nonpayable G -codes and severity modifi ers, for services furnished on or after January 1, 2013.  (Reference: 42CFR410.61 and 42CFR410.105 (for CORFs).  NOTE : The regulatory requirements at 42CFR410.61 and 42CFR410.105 (for CORFs) for the plan of cares long- term goals to be consistent with func tional impairments identified for purposes of functional reporting, were removed by the CY 2019 Physician Fee Schedule final rule, CMS -1693- F.  Functional reporting and its associated documentation requirements are no longer applicable for claims or medica l records for dates of service on and after January 1, 2019.   See the NOTE  at the beginning of Section 220.4 for more information.    The type of treatment may be PT, OT, or SLP, or, where appropriate, the type may be a description of a specific treatment or intervention.  (For example, where there is a single evaluation service, but the type is not specified, the type is assumed to be c onsistent with the therapy discipline (PT, OT, SLP) ordered, or of the therapist who provided the evaluation.)  Where a physician/NPP establishes a plan, the plan must specify the type (PT, OT, SLP) of therapy planned.