Article - Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067)

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, revises 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 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 Z51.89 ICD-10-CM code.Article TextThis article gives guidance for billing, coding, and other guidelines in relation to local coverage policy Outpatient Physical and Occupational Therapy Services L34049.General Guidelines for Claims submitted to Part A or Part B MAC: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. 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. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.Advance Beneficiary Notice of Non-coverage (ABN) Modifier GuidelinesAn ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, -GX, -GY, or GZ, as appropriate.The GA modifier (Waiver of Liability Statement Issued as Required by Payer Policy) should be used when physicians, practitioners, or suppliers want to indicate that they anticipate that Medicare will deny a specific service as not reasonable and necessary and they do have an ABN signed by the beneficiary on file. Modifier GA applies only when services will be denied under reasonable and necessary provisions, sections 1862(a)(1), 1862(a)(9), 1879(e), or 1879(g) of the Social Security Act. Effective April 1, 2010, Part A MAC systems will automatically deny services billed with modifier GA. An ABN, Form CMS-R-131, should be signed by the beneficiary to indicate that he/she accepts responsibility for payment. The -GA modifier may also be used on assigned claims when a patient refuses to sign the ABN and the latter is properly witnessed. For claims submitted to the Part A MAC, occurrence code 32 and the date of the ABN is required.Modifier GX (Notice of Liability Issued, Voluntary Under Payer Policy) should be used when the beneficiary has signed an ABN, and a denial is anticipated based on provisions other than medical necessity, such as statutory exclusions of coverage or technical issues. An ABN is not required for these denials, but if non-covered services are reported with modifier GX, will automatically be denied services.The GZ modifier should be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an ABN signed by the beneficiary. If the service is statutorily non-covered, or without a benefit category, submit the appropriate CPT/HCPCS code with the -GY modifier. An ABN is not required for these denials, and the limitation of liability does not apply for beneficiaries. Services with modifier GY will automatically deny.Documentation RequirementsThe patients medical record should include but is not limited to:The assessment of the patient by the ordering provider as it relates to the complaint of the patient for that visit,Relevant medical historyResults of pertinent tests/proceduresSigned and dated office visit record/operative report (Please note that all services ordered or rendered to Medicare beneficiaries must be signed.)Therapy services shall be payable when the medical record and the information on the claim consistently and accurately report covered therapy services. Documentation must be legible, relevant and sufficient to justify the medical necessity of the services billed.Medicare requires a legible identifier of the person(s) who provided the service. The method used shall be a hand written or an electronic signature to sign an order or other medical documentation for medical review purposes. Electronic or hand written signatures that have been communicated through facsimile are also acceptable.Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:Paint a picture of the patients impairments and functional limitations requiring skilled intervention;Describe the prior functional level to assist in establishing the patients potential and prognosis;Describe the skilled nature of the therapy treatment provided;Justify that the type, frequency and duration of therapy is medically necessary for the individual patients condition;Clearly document both Timed Code Treatment Minutes and Total Treatment Time in order to justify the units billed;Identify each specific skilled intervention/modality provided to justify coding;Provide outcome measures or results f other assessment tools or measurement instruments, as appropriate, to demonstrate the clinical progress being attained by the patient in regards to the patients identified functional limitations.Documentation may be submitted in any format as long as all the necessary information is captured. Forms 700 & 701 are not required documents. The documentation must establish that the patient needs the unique skills of a therapist to improve functioning. This is accomplished through a description of the patients condition, and any complexities that impact that condition. Not only should documentation describe the needs of the patient that require the unique skills of a therapist, but should also describe the services provided that required the expertise, knowledge, clinical judgment, decision making and abilities of a clinician that assistants, qualified auxiliary personnel, caretakers or the patient cannot provide independently. A therapists skills may be documented, for example, by the descriptions of the skilled treatment, the changes made to the treatment due to an assessment of the patients needs on a particular treatment day, or due to progress judged sufficient to modify the treatment toward the next more complex or difficult task.Documentation should establish the variables that influence the patients condition, especially those factors that influence the therapists (or clinician's) decision to provide more services than are typical for the individuals condition. Documentation should establish through objective measurements that the patient is making progress toward goals. When regression or plateaus occur, the reasons for the lack of progress should be noted to justify continued treatment.Only a clinician may perform an initial examination, evaluation, reevaluation and assessment or establish a diagnosis or a plan of care. The clinician may include as part of the evaluation or reevaluation, objective measurements or observations made by a PTA or OTA within their scope of practice, but the clinician must actively and personally participate in the evaluation or reevaluation. The clinician may not merely summarize the objective findings of others or make judgments drawn from the measurements and/or observations of others.Initial EvaluationThe initial evaluation, which must be performed by a clinician, should document the medical necessity of a course of therapy through objective findings and subjective patient self-reporting. Documentation of the initial evaluation should list the conditions being treated and any complexities that make treatment more lengthy or difficult.Where it is not obvious, describe the impact of the conditions and complexities so that it is clear to the medical reviewer that the services planned are appropriate for the individual.The initial evaluation establishes the baseline data necessary for assessing expected rehabilitation potential through functional testing using standardized scales appropriate to the patient's diagnosis, the setting of realistic goals and the objective measurement of progress using these same scales. Initial evaluations need to provide objective, measurable documentation of the patients impairments and how any noted deficits affect ADLs/IADLs and result in functional limitations. Functional limitations refer to the inability to perform actions, tasks and activities that constitute the usual activities for the patient. Functional limitations must be meaningful to the patient and caregiver, and must have potential for improvement. In addition, the remediation of such limitations must be recognized as medically necessary.To support medical necessity, the evaluation should include the following items.Presenting condition or complaint...."What brings the patient to therapy at this time?Patients should exhibit a significant change from their usual physical or functional ability to warrant an evaluation.Provide an objective description of the changes in function that now necessitate skilled therapy. Simply stating decline in function does not adequately justify the initiation of therapy services.Diagnosis and description of specific problem(s) to be evaluatedInclude area of the body, and conditions and complexities that could impact treatmentSubjective complaints and date of onsetRelevant medical historyApplicable medical history, medications, comorbidities (factors that make therapy more complicated or require extra precautions)Prior diagnostic imaging/testing resultsPrior therapy history for the same diagnosis, illness or injuryIf recent therapy was provided, documentation must clearly establish that additional therapy is reasonable and necessarySocial support/environment ?Does the patient live alone, with a caregiver, in a group home, in a residential care facility, in a skilled nursing facility (SNF), etc? ?What level of support is available, and what level of independence is required for the patient to be safe in the home environment?Does the home situation have obstacles that the patient must overcome (e.g., stairs without handrails)?What are the patients usual responsibilities in the home environment?Prior level of functionKey piece of information used for establishing potential, prognosis and realistic functional goalsFunctional status just prior to the onset of the treating condition requiring therapyRecord in objective, measurable and functional termsFunctional testing ?Objectively measure and/or describe the patients current level of functioning.Examples, based on the patients need, may include:mobility status (transfers, bed mobility, gait, etc);self-care dependence (toileting, dressing, grooming, etc);meaningful ADLs/IADLs;pain, and how it limits function; andbalance.Objective impairment testingTesting done to determine the source or cause of the functional limitation(s), such as ROM, manual muscle testing, coordination, tone assessment, balance etc.Use concise, objective measurements. Avoid minimal/moderate/severe types of descriptions when more specific definitions or measurements are available. For example, when measuring shoulder flexion AROM, document degrees of motion, rather than documenting, Shoulder flexion: minimal loss of motion.Assessment