(Medicare Benefit Policy Manual)

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   There are some conditions for which respiratory therapy services may be indi cated.  However, respiratory therapy performed as part of a standard protocol without regard to the individual patient's actual condition, capacity for improving, and the need for such services as established, is not reasonable and medically necessary.  Al l respiratory therapy services must meet the test of being reasonable and medically necessary pursuant to 1862(a)(1)(A) of the Act.  Determinations of medical necessity are made based on local contractor decisions on a claim -by-claim basis.   The three H CPCS codes G0237, G0238, and G0239 are specific to services provided under the respiratory therapy plan of treatment and, as such, are not designated as subject to the therapy caps.   C. Patient Education Programs   Instructing a patient in the use of equipm ent, breathing exercises, etc. may be considered reasonable and necessary to the patient's respiratory therapy plan of treatment and can usually be given to a patient during the course of treatment by the respiratory therapist.  These educational instructi ons are bundled into the covered service and separate payment is not made.  40.6 - Prosthetic and Orthotic Devices  and Supplies  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  Prosthetic devices, other than dental devices and renal dialysis machines, are covered CORF services if they are included in the rehabilitation plan of treatment.  Prosthetic devices (other than dental) are defined as devices that replace all or part of an internal body organ (including contig uous tissue), or which replace all or part of the function of a permanently inoperative or malfunctioning internal body organ.  If the patients medical record, including the judgment of the physician, indicates the condition is of long and indefinite dura tion, the test of permanence is considered met.   Coverage of a prosthetic device includes all services necessary for formulating its design, material, and component selection; measurement, fittings, static and dynamic alignments; and instructing the patien t in its use.  Such coverage is included as an integral part of the fabrication of the device.   Orthotic devices include but are not limited to leg, arm, back, and neck splints or braces.  They are rigid and semi -rigid devices supporting weak or deformed body members or restricting or eliminating motion in a diseased, dysfunctional, or injured body part.  Elastic stockings, garter belts, and similar devices do not come within the scope of the definition of an orthotic or a device.  Back braces include, but  are not limited to, special corsets, e.g., sacroiliac, sacrolumbar, dorsolumbar corsets and belts.  Examples of prosthetic devices include artificial legs and arms.  Residual limb stockings and harnesses (including replacements) are also covered when thes e appliances are essential to the effective use of the artificial limb.   In general, orthotics and prosthetics are covered when furnished in conjunction with a physician's service or on a physician's order.  These devices are covered CORF services if inclu ded as part of the rehabilitation plan of treatment.  The payment for an orthosis or prosthesis includes its design, materials, measurements, fabrications, testing, fitting, adjustments and training in the use of the device.   Adjustments to an artificial limb or other appliance required by a change in the patient's condition are covered when ordered by the patients referring or CORF physician.  Adjustments, repairs and replacements in these cases are covered even when the item had been in use before the be neficiary enrolled in Medicare Part B so long as the device continues to be medically required.   CORFs may not bill separately for the supplies they furnish except for those cast and splint supplies that are used in conjunction with the corresponding Curre nt Procedural Terminology code.  40.7 - Social and/or Psychological Services  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  Social and psychological  services are covered CORF services if physical therapy services represent the predominate rehabilitation services provided in the CORF.  Social and psychological services must be included as part of, or directly relate to, the rehabilitation plan of treatment.   Social and psychological  services must contribute to the i mprovement of the individuals rehabilitation condition and may not relate to a mental health diagnosis.  Social and psychological services include t he assessment and treatment of a CORF patients mental health and emotional functioning and the response to, and rate of progress of the patients  rehabilitation plan of treatment including physical therapy services, occupational therapy services, speech -language pathology services and respiratory therapy services.    CORF s ocial and/or psychological  covered serv ices are the same, regardless of whether they are provided by a qualified social worker , as defined at 42CFR485.70(l), or a psychologist , as defined at 42CFR485.70(g).  T herefore, a CORF may elect to provide these services when they are indicated.  Qualifications for individuals providing CORF social and psychological services are, at a minimum, a Bachelors of Science Degree for a social worker and a Masters -level degree for a psychologist.  40.8 - Nursing Services  (Rev. 111, Issued:  09- 25-09; Effective Da te:  07 -07-08; Implementation Date:  10 -26-09)  CORF nursing services may only be provided by an individual meeting the qualifications of a registered nurse , as defined at 42CFR485.70(h).  They must relate to, or be a part of, the rehabilitation plan of treatment.   CORF nursing services must be reasonable and medically necessary and are provided as an adjunct to the rehabilitation plan of treatment.  For example, a registered nurse may perform or instruct a patient, as appropriate, in the proper procedure  of in and out urethral catheterization, tracheostomy tube suctioning, or the cleaning for ileostomy or colostomy bags.  Nursing services may not substitute for or supplant the services of physical therapists, occupational therapists, speech -language pat hologists and respiratory therapists, but instead must support or further the services and goals provided in the rehabilitation plan of treatment.   CORF nursing services must be provided by a registered nurse and may only be coded as HCPCS code G0128 indic ating that CORF nursing services were provided.   40.9 - Drugs and Biologicals  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  There are no drugs and biologicals currently identified as appropriate for a therapy rehabilitation plan of treatment, CORFs may not submit claims for drugs and biologicals.  If a drug or biological is identified in the future, the administration of such shall be consistent with the limitations established at 42CFR410.29.  40.10 - Home Envi ronment Evaluation  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  One single, home environment evaluation visit is a covered CORF service if it is included in the physical therapy, occupational therapy or speech -language pathology plan of treatment.  The single home environment evaluation visit allows the evaluation of the patient in the home environment and the assessment of the potential impact on the patients rehabilitation goals.   The purpose of the home envir onment evaluation is to permit the rehabilitation plan of treatment to be tailored to take into account the patients home environment.  However, Medicare does not pay for physical alterations to the home that facilitates the patients rehabilitation.  The  patient must be present during the home environment evaluation visit, which must be performed by the physical therapist, occupational therapist or speech -language pathologist, as appropriate.  The patients presence is necessary to fully evaluate the potential impact of the home situation on the rehabilitation goals as specified in the plan of treatment.   The home environment evaluation visit is not covered as a routine service for all CORF patients.  It is covered only if, in establishing or carrying out the physical therapy, occupational therapy, or speech -language pathology  plan of treatment, there is a clear indication that the home environment might adversely affect the patients rehabilitation.  Coverage is limited to the services of one professional, either a physical therapist, occupational therapist, or a speech -language pathologist who provides the therapy services established in the corresponding plan of treatment that identifies the necessity for the home environment evaluation visit.   40.11 - Vaccines  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  A CORF may provide pneumococcal pneumonia, influenza virus, and hepatitis B vaccines to its patients.  While not included as a service under the CORF benefit, Medicare will make payment to the CORF for certain vaccines and their administration provided to CORF patients (CY 2008 PFS Rule 72 FR 66293) .  The following three vaccinations are covered in a CORF if a physician who is a doctor of medicine or osteopathy orders it for a CORF patient:    Pneumococcal pneumonia vaccine and its administration;    Hepatitis B vaccine and its administration furnished to a beneficiary who is at high or intermediate risk of contracting hepatitis B; and    Influenza virus vaccine and its administration   Payment for covered pneumococcal pneumonia, influenza virus, and hepatitis B va ccines provided in the CORF setting is based on 95 percent of the average wholesale price.  The CORF registered nurse provides administration of any of these vaccines using HCPCS codes G0008, G0009 or G0010 with payment based on CPT code 90471.   Transmitt als Issued for this Chapter  Rev #  Issue Date  Subject  Impl Date  CR#  R255BP  01/25/2019 Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018 02/26/2019  11120  R165BP  12/21/2012 Implementing the Claims -Based Data Collection Requirement for Outpatient Therapy Services --  Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 01/07/2013  8005 R163BP  11/30/2012 Implementing the Claims -Based Data Collection Requirement for Outpatient Therapy Services --  Section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012  Rescinded and replaced by Transmittal 165  01/07/2013  8005 R158BP  08/24/2012 Implementing the Claims -Based Data Collection Requirement for Outpatient Therapy Services --  Section 3005(g) of the Middle  Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012  Rescinded and replaced by Transmittal 163  01/07/2013  8005 R111BP  09/25/2009 Comprehensive O utpatient Rehabilitation Facility (CORF) Services  10/26/2009  6005 R21BP  09/24/2004 Medicare Comprehensive Outpatient Rehabilitation Facility Coverage  10/25/2004  3315 R1BP  10/01/2003 Introduction to the Benefit Policy Manual  N/A N/A Back to top of Chapter