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(Medicare Benefit Policy Manual)
Medicare Benefit Policy Manual  Chapter 12 - Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage   Table of Contents  (Rev. 255, 01- 25-19)  Transmittals for Chapter 12   10 - Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by Medicare 20 - Required and Optional CORF Servic es 20.1 -  Required Services  20.2 -  Optional CORF Services  30 - Rules for Provision of Services  30.1 -  Rules for Payment of CORF Services  40 - Specific CORF Services  40.1 -  Physicians Services  40.2 -  Physical Therapy Services  40.3 -  Occupational Therapy Services  40.4  Speech Language  Pathology Services  40.5 -  Respiratory Therapy Services  40.6 -  Prosthetic and Orthotic Devices  and Supplies  40.7 -  Social and/or Psychological Services  40.8 -  Nursing Services  40.9 -  Drugs and Biologicals  40.10 -  Home Environment Evaluations  40.11 -  Vaccines  10 - Comprehensive Outpatient Rehabilitat ion Facility (CORF) Services Provided by Medicare  (Rev. 111, Issued:  09- 25-09; Effective Date:  07 -07-08; Implementation Date:  10 -26-09)  The purpose of a Comprehensive Outpatient Rehabilitation Facility (CORF) is to permit the beneficiary to receive mul tidisciplinary rehabilitation services at a single location in a coordinated fashion.  Section 1861(cc) of the Social Security Act specifies that no service may be covered as a CORF service if it would not be covered as an inpatient hospital service if provided to a hospital patient.  This does not mean that the beneficiary requires a hospital level of care or meets other requirements unique to hospital care.  This provision merely requires that the service, if otherwise covered, would be covered if provide d in a hospital.
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CORF services are covered only if they relate directly to the rehabilitation for the treatment of injured, disabled, or sick patients.  CORF services are not covered if not reasonable and medically necessary for the diagnosis, or treatmen t of illness, or injury, or to improve the function of a malformed body member.  Thus, there must be potential for restoration or improvement of lost or impaired functions.  For example, treatments involving repetitive exercises (i.e., maintenance programs , general conditioning or ambulation) that do not require the skilled services of physical therapists, occupational therapists, speech -language pathologists or respiratory therapists are not covered.  Nonmedical personnel such as family members or exercise instructors could perform these activities in the patients residence.  It is not reasonable and medically necessary for such activities to be performed in a CORF setting by CORF personnel.  See 42CFR 410.100 and sections 20.1 and 20.2 of this chapter for  the list of required and optional services provided in a CORF.   CORF services do not include the following: a) provision of hyperbaric oxygen services, b) infusion therapy services, c) cardiac rehabilitation services, or d) diagnostic sleep studies. They do not meet the definition of a CORF services and/or they do not relate to the rehabilitation plan of treatment.  These services, and other services not specifically listed as CORF services, may be covered under another Medicare benefit category, such as physician services, incident -to physician services, and diagnostic services.  Physical therapy, occupational therapy, and speech- language pathology services may be furnished in the patients home, as CORF services, when payment for these therapy services is  not otherwise made under the Medicare home health benefit.  However, since the CORF premise is the primary location for furnishing these services, it is expected that a clear majority of the physical therapy, occupational therapy and speech -language pathology services delivered will be provided on the CORF premises for all CORF patients.
(Medicare Benefit Policy Manual)
In addition to the above noted services, which may be provided in the home, a single home environment evaluation visit is a covered CORF service if it is included in the rehabilitation plan of treatment.  The patient must be present during the home environment evaluation that is performed by the physical therapist, occupational therapist, or speech- language pathologist, as appropriate.  The patients presence is necessary to assess the patients current or future ability to function safely in the home environment and to determine the potential impact the home situation will have on the patients rehabilitation goals.   Services provided under the incident to benefit may not be recognized as CORF services.  Services furnished by CORF personnel, including registered nurses, physical therapists, occupational therapists, speech- language pathologists, respiratory therapists, social workers and psychologists are not considered as  furnished incident -to physician services.   The CORF physician must be present in the facility for a sufficient time to ensure that CORF services are provided in accordance with accepted principles of medical practice. All CORF services must be provided wi thin acceptable professional standards and practice (42CFR485.70, and 410.100).   20 - Required and Optional CORF Services (Rev. 1, 10- 01-03) A3-3180, CORF -250  20.1 - Required Services  (Rev.  255, Issued: 01- 25-19, Effective: 01-  01- 19, Implementation: 02- 26-19)  Section 1861(cc) of the Act defines a CORF as a facility that is primarily engaged in providing outpatient rehabilitation to the injured and disabled or to patients recovering from illness.  The CORF must provide the following core CORF services : a) CORF physicians services, b) physical therapy services, and c) social and/or psychological services.  Physical therapy services should comprise a clear majority of the total CORF services provided when the CORF offers the three core CORF services.  A  physician must certify, as a condition of payment, that all CORF services are required because the individual needs skilled rehabilitation services.  Skilled rehabilitation services are defined as services requiring the skills of physical therapists, speech -language pathologists or occupational therapists. In addition, respiratory therapists are recognized to provide skilled respiratory therapy services only under the CORF benefit.
(Medicare Benefit Policy Manual)
A CORF is recognized as a provider of rehabilitation services.  It is paid  under the physician fee schedule for all CORF services and items except for CORF physician services (which are administrative in nature), drugs and biologicals  and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) .  To participate i n Medicare, a CORF must furnish at least the following:    CORF  physicians services -  includes  professional services performed by a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the State in which he/she performs se rvices.  These services are administrative in nature, such as consultation with, and medical supervision of, CORF qualified personnel, patient case review conferences, utilization review, and review of the rehabilitation plan of treatment, as  appropriate .  The physician must ensure that CORF services are provided in accordance with accepted principles of medical practice, medical direction and medical supervision.  Subsequent to completing a 1-year hospital internship, the physician must have completed at l east 1 -year of training in the medical management of patients requiring rehabilitative services (42CFR485.70) or at least 1 year of full -time or part- time experience in a rehabilitation setting providing physician services similar to those required in a rehabilitation facility.  A physician who specializes only in pulmonary rehabilitation does not meet these requirements as he/she is not likely to have the experience needed to medically manage patients that need physical therapy, occupational therapy and sp eech-language pathology services.  Diagnostic or therapeutic services provided to a CORF patient by the CORF physician or other physician are not CORF physician services.  Such services are separately payable to the physician and not the CORF under the phy sician fee schedule at the non -facility payment amount.  These services should be billed as if they were provided in the physicians office.  (See 42CFR410.100(a) and section 40.1.)    Physical therapy services -  include testing, measurement, assessment and treatment of the function, or dysfunction, of the neuromuscular, musculoskeletal, cardiovascular and respiratory system, and establishment of a maintenance therapy program for an individual whose restoration potential has been reached  (See 42CFR410.100(b) and section 40.2); and
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 Social and/or psychological services  are covered only if the patients physician or the CORF physician establishes that the services directly relate to the patients rehabilitation plan of treatment and are needed to achieve the g oals in the rehabilitation plan of treatment.  Social and/or psychological services include only those services that address the patients response and adjustment to the rehabilitation treatment plan; rate of improvement and progress towards the rehabilita tion goals, or other services as they directly relate to the physical therapy, occupational therapy, speech- language pathology, or respiratory therapy plan of treatment being provided to the patient.  CORF social and/or psychological services do not include services for mental health diagnoses  (See 42CFR410.100(h) and section 40.7.)   To receive Medicare payment for covered services, the CORF must have adequate space and equipment necessary for any of the services provided.  Additionally, in order to accept  a patient,  the CORF must be able to provide all of the services required by the patient, as established in the rehabilitation plan of treatment.  If the CORF does not have the necessary qualified personnel to provide the service(s), it must arrange for the service(s) to be provided at the CORF, as needed.   Functional reporting is required 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.)   NOTE : Functional reporting and its associated documentation requirements are no longer applicable for claims or medical records for dates of service on and after January 1, 2019.  See  the NOTE  at the beginning of subsection F in Section 30 below for more information.    The CORF services are subject to the Medicare Part B deductible and coinsurance provisions. T he CORF may bill the beneficiary only for the unmet portion of the deductible and 20 percent of the fee schedule amount for covered services.   20.2 - Optional CORF Services  (Rev. 111, Issued: 09- 25-09; Effective Date: 07 -07-08; Implementation Date: 10 -26-09)
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20.2 - Optional CORF Services  (Rev. 111, Issued: 09- 25-09; Effective Date: 07 -07-08; Implementation Date: 10 -26-09)  In addition to the three required core CORF services, the CORF may furnish any of the other covered and medically necessary items and services listed in 20.2 .  These optional services must directly relate to, and be consistent with, the rehabilitation plan of treatment, and must be necessa ry to achieve the patients rehabilitation goals.  When a CORF provides occupational therapy, speech- language pathology and/or respiratory therapy services in addition to the required physical therapy services, the physical therapy services shall represent  the predominate rehabilitation service provided.  For discussion of payment rules see section 30.1.  The CORF may provide any or all of the following rehabilitation services:   Occupational therapy -  services include assessment of an individuals level of independent functioning, selection and teaching of task- oriented therapeutic activities to restore sensory -integrative functions, teaching of compensatory techniques to permit an individual with a physical or cognitive impairment or limitation to engage in  daily activities (See 42CFR410.100(c) and section 40.3);    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);
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 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
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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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.