(Medicare Benefit Policy Manual)

 Speech -  Language pathology -  services for the diagnosis and treatment of speech and language disorders that create difficulties in communication or dysphagia (swallowing difficulties).  (See 42CFR410.100(d) and section 40.4);    Respiratory therapy - services includes only those services that can be appropriately provided to CORF patients by a qualified respiratory therapist (42CFR485.70(j)) under a physician- established respiratory therapy plan  of treatment in accordance with current medical and clinical standards  (See 42CFR410.100(e) and section 40.5);    Prosthetic and orthotic devices -  includes testing, fitting, or training in the use of such devices  (See 42CFR410.100(f) and (g) and section 40.6);    Nursing  includes nursing services (e.g., teaching self catheterization) that directly relate to and are specified in the rehabilitation plan of treatment, are necessary for the attainment of the rehabilit ation goals and are  provided by a registered nurse as defined in 42CFR485.70(h).  (See 42CFR410.100(i) and section 40.8);    Drugs - and biologicals  which are not excluded from Part B payment, including those that are self -administered, specified at 42CFR410.29, however, there are no drugs identified which can be provided in a CORF (Calendar Year (CY) 2008 Physician Fee Schedule (PFS) Rule 72 FR 66293) .  (See 42CFR410.100(j) and section 40.9);    Supplies and  Durable Medical Equipment (DME)  CORFs may not bil l separately for the supplies they furnish except for those cast and splint supplies that are used in conjunction with the corresponding Current Procedural Terminology code. (See 42CFR410.100(k) and section 40.6);  and   A single physical therapy, occupational therapy, or speech -language pathology home environment evaluation visit as appropriate  this includes evaluating  the potential impact of the home environment on the rehabilitation goals ( See 42CFR410.100(l)  and section 40.10).   30 - Rules for Provision  of Services  (Rev.  255, Issued: 01- 25-19, Effective: 01-  01- 19, Implementation: 02- 26-19)   A.  Place of Treatment   In general, CORF services, except for physical therapy, occupational therapy, speech -language pathology services, and the single home environment evaluation, must be furnished on the premises of the CORF.  Physical therapy, occupational therapy, and speech -language pathology services provided in the home are not covered as CORF services if payment for such services is made under the Medi care home health benefit.  Although, physical therapy, occupational therapy, and speech -language pathology services can be furnished in the patients home, a majority of these services must be provided on the CORF premises for all CORF patients.  A 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.   A CORF cannot provide items or services that are not included in the definition of  CORF services at 42CFR410.100 other than vaccines (CY 2008 PFS Rule 72 FR 66293) .  Those services included in the definition of CORF services are covered only to the extent that they support or further the rehabilitation plan of treatment.    B.  Personnel  Qualification Requirements   Services must be furnished or supervised by qualified personnel in accordance with regulation 42CFR485.70.  Payment for social and/or psychological services, nursing services and respiratory therapy services is made when provid ed as specified in sections 40.7, 40.8 and 40.5 respectively of this chapter, as appropriate.   Determinations regarding whether services are furnished in accordance with the conditions of participation and under the supervision of qualified personnel as noted at section 20.2 are primarily the responsibility of the State survey agency responsible for survey and certification of the facility.  If services are not being furnished or appropriately supervised by qualified personnel, the Medicare contractor will withhold payment until the matter is resolved, as appropriate.  C.  Services Furnished Under Arrangements   Any CORF service defined in 20 or 40  may be furnished under arrangement and mus t meet the requirements of Pub. 100- 01 chapter 5, section 10.3.  D.  Referral for Treatment   To become a patient of a CORF, the beneficiary must be under the care of a physician who certifies that the beneficiary needs skilled rehabilitation services.   The referring physician must advise the CORF of the beneficiarys medical history, current diagnosis and medical findings, desired rehabilitation goals, and any contraindications to specific activity or intensity of  rehabilitation services.  If the rehabilita tion goals for physical therapy, occupational therapy, speech -language pathology or respiratory therapy services are not specified by the referring physician, the CORF physician must establish them.   E.  Plan of Treatment   The CORF services must be furnished under a written rehabilitation plan of treatment established and signed  by a physician  who has recently evaluated the patient .  It is expected that the physician will establish the rehabilitation plan of treatment in consultation with the physical therapist, occupational therapist or speech -language pathologist who will provide the actual therapy.  The physician wholly establishes the respiratory therapy plan of treatment.  The physician may be either a CORF physician or the patients referring physician if the physician provides a detailed rehabilitation plan of treatment that meets the following requirements.   The rehabilitation plan of treatment must be established and signed by a physician prior to the commencement of treatment in the CORF setting and contain the diagnosis, the type, amount, frequency, and duration of skilled rehabilitation services to be performed, and the anticipated skilled rehabilitation goals.  The services furnished under the rehabilitation plan o f treatment must be reasonable and medically necessary and relate directly to the rehabilitation of injured, disabled, or sick patients.  The skilled rehabilitation goals for physical therapy, occupational therapy, and speech -language pathology plans of tr eatment must be consistent with those used for the Functional reporting pursuant to 410.105(d). For related documentation requirements, see subsection F below. For more details on documentation requirements, refer to chapter 15, section 220.3, of this manual.  NOTE : Functional reporting and documentation requirements are no longer applicable for claims for dates of service on and after January 1, 2019. For more information, refer to the NOTE  in subsection F below.      The CORF physician or the  referring  physician for physical therapy, occupational therapy and speech -language pathology services, must review the plan of treatment at least once every 90 days certifying that the patient needs or continues to need skilled rehabilitation services, the rehabili tation plan of treatment is being followed and that the patient is making progress in attaining the established rehabilitation goals.  The 90- day period begins with the first day of rehabilitation therapy.   For respiratory therapy services, the CORF physic ian or the patients referring physician must review the rehabilitation plan of treatment at least every 60 days.  The 60 -day period begins with the first day of respiratory therapy treatment.  (For survey and certification the plan of treatment review must meet the requirements at 42CFR 485.58(b)).  When the patient has reached a point where no further progress is being made toward one or more of the rehabilitation  goals, or the skills of a therapist are no longer required, Medicare coverage ends with respect to that aspect of the rehabilitation plan of treatment.   F.  Functional Reporting and Documentation Requirements for Physical Therapy, Occupational Therapy, and Speech -language Pathology Services.   NOTE : In the calendar year (CY) 2019 Physician Fee Sch edule (PFS) final rule, CMS-1693 -F, after consideration of stakeholder comments for burden reduction, a review of all of the requirements under section 3005(g) of Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA), and in light of the statutor y amendments to section 1833(g) of the Act, via section 50202 of Bipartisan Budget Act of 2018 to repeal the therapy caps, CMS concluded that continued collection of functional reporting data through the same or reduced format would not yield additional information to inform future analyses or to serve as a basis for reforms to the payment system for therapy services. To reduce the burden of reporting for providers of therapy services, the CY 2019 PFS final rule ended the requirements of reporting the funct ional limitation nonpayable HCPCS G -codes and severity modifiers on claims for therapy services and the associated documentation requirements in medical records, effective for dates of service on and after January 1, 2019.  The rule also revised regulation text at 42 CFR 410.59, 410.60, 410.61, 410.62, 410.105, accordingly.    The instructions below apply only to dates of service when the functional reporting requirements were effective, January 1, 2013 through December 31, 2018.    Functional reporting is r equired on claims for CORF physical therapy, occupational therapy, and speech -language pathology services by section 3005(g) of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012.  (See 42CFR410.105 and 42CFR410.59, 60, and 62.)   The regul ations implementing Section 3005(g) of the MCTRJCA require that nonpayable G-codes  and severity modifiers be used to report the functional status of CORF patients receiving physical therapy, occupational therapy, and speech -language pathology services. Th is functional reporting is required to be included on claims at the beginning of treatment/outset of therapy, at specified reporting intervals which are consistent with those for progress reporting, and at discharge from therapy.  In addition, functional reporting is required when an evaluative procedure, including a re -evaluative one, is billed. The functional G -codes and severity modifiers used in reporting the patients functional status shall be documented in each patients medical record.  Refer to cha pter 15, section 220 of this manual for instructions on selecting and documenting these functional G -codes and severity modifiers in the patients medical record.   For details about the functional reporting requirements for G -codes and severity modifiers o n claims for therapy services, see Pub. 100- 04, Medicare Claims Processing Manual, chapter 5, section 10.6.  30.1  Rules for Payment of CORF Services (Rev.  255, Issued: 01- 25-19, Effective: 01-  01- 19, Implementation: 02- 26-19)  The payment basis for CORF  services is 80 percent of the lesser of: (1) the actual charge for the service or (2) the physician fee schedule amount for the service when the physician fee schedule establishes a payment amount for such service.  Payment for CORF services under the phy sician fee schedule is made for physical therapy, occupational therapy, speech -language pathology and respiratory therapy services, as well as the nursing and social and/or psychological services, which are a part of, or directly relate to, the rehabilitation plan of treatment.  Payment for covered durable medical equipment, orthotic and prosthetic (DMEPOS) devices and supplies provided by a CORF is based upon: the lesser of 80 percent of actual charges or the payment amount established under the DMEPOS fee schedule; or, the single payment amount established under the DMEPOS competitive bidding program, provided that payment for such an item is not included in the payment amount for other CORF services.   If there is no fee schedule amount for a covered CORF item or service, payment should be based on the lesser of 80 percent of the actual charge for the service provided or an amount determined by the local Medicare contractor.   The following conditions apply to CORF physical therapy, occupational therapy, and speech -language pathology services;    Claims must contain the required functional reporting.  (Reference: Sections 42 CFR 410.105.)  Refer to Pub. 100- 04, Medicare Claims Processing Manual, chapter 5, section 10.6.  NOTE : Functional reporting and documentation requirements are no longer applicable for claims for dates of service on and after January 1, 2019.  For more information, refer to subsection F in section 30 above.