Notification

Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services


Notification Issue Date: 08/01/2019

This new policy becomes effective 09/01/2019 and applies to outpatient facility providers. Multiple procedure payment reduction guidelines for multiple therapies apply to physical, occupational, and speech therapy services designated as Always Therapy that are reported by the same provider, for the same individual, on the same date of service.

  • The procedure code with the highest total allowance is eligible for reimbursement at 100 percent of the provider's applicable contracted rate.
  • Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.


Claim Payment Policy


Title:Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services

Policy #:00.01.68


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract.

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.


This policy applies to outpatient facility providers billing on a CMS-1450 (UB-04) claim form, or the equivalent form 837i, for members enrolled in all Company products.

Multiple procedure payment reduction (MPPR) guidelines for physical, occupational, and speech therapy services designated as Always Therapy are used to determine the provider's reimbursement for eligible therapy services.

Refer to Attachment A of this policy for services that are designated as Always Therapy services.

MPPR guidelines apply when multiple physical, occupational, and speech therapy services designated as Always Therapy are reported by the same provider, for the same individual, on the same date of service.
  • The procedure code with the highest total allowance is eligible for reimbursement at 100 percent of the provider's applicable contracted rate.
  • Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

These MPPR guidelines only apply to services that are designated as Always Therapy and would not impact reimbursement consideration for services that are not designated as Always Therapy.

NONCOVERED AND NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Multiple procedure payment reduction guidelines for physical, occupational, and speech therapy services are not applied to services that are non-covered or not eligible for separate reimbursement consideration.

REQUIRED DOCUMENTATION

These Always Therapy codes require a therapy modifier to indicate that the services are furnished under a physical, occupational, or speech therapy plan of care.

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
Guidelines

This claim payment rationale applies only to the procedure codes in Attachment A of this policy. Claims reported with services designated as Always Therapy are processed in accordance with this policy. When another policy on physical, occupational, or speech therapies exists, the criteria and coverage information listed in the medical policy must also be met.

Multiple procedure payment reduction (MPPR) guidelines for services that are designated as Always Therapy are based on the date of service regardless of the claim submission date or date received.

Description

In accordance with The Centers for Medicare & Medicaid Services (CMS), the Company has established claims processing guidelines for multiple physical, occupational, and speech therapy services that are designated as Always Therapy.

CMS designates certain procedure codes as Always Therapy. Such procedure codes are assigned a therapy disposition code of "5" by CMS. These codes always represent therapy services when rendered by therapists or by practitioners who are not therapists in situations where the service provided is integral to an outpatient rehabilitation therapy plan of care. For these situations, these codes must always have a therapy modifier.
References


Centers for Medicare & Medicaid Services (CMS). MLN Matters Number MM8206. Effective April 1, 2013. [CMS Website]. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/MM8206.pdf. Accessed March 15, 2019.

Centers for Medicare & Medicaid Services (CMS). Annual Therapy Update. 2019 Therapy Code List and Dispositions. [CMS Website]. Available at:
https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html. Accessed March 15, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 5: Part B Outpatient Rehabilitation and CORF/OPT Services. Revised 03/09/18. [CMS Website]. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf. Accessed March 15, 2019.

Novitas Solutions. Multiple Procedure Payment Reduction. [Novitas Solutions Web site]. Last modified: 03/14/2019. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?centerWidth=100%25&contentId=00147106&leftWidth=0%25&rightWidth=0%25&showFooter=false&showHeader=false&_adf.ctrl-state=tl57mjwsj_4&_afrLoop=309444304661771#!. Accessed March 15, 2019.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

N/A


Revenue Code Number(s)

N/A


Misc Code

Modifiers:

CO Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

CQ Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant

GN Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care

GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care

GP Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care



Coding and Billing Requirements


Cross References

Attachment A: Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
Description: Multiple Reduction Always Therapy Procedure Codes



Policy History

00.01.68
09/01/2019This new policy becomes effective 09/01/2019 and applies to outpatient facility providers. Multiple procedure payment reduction guidelines for multiple therapies apply to physical, occupational, and speech therapy services designated as Always Therapy that are reported by the same provider, for the same individual, on the same date of service.
  • The procedure code with the highest total allowance is eligible for reimbursement at 100 percent of the provider's applicable contracted rate.
  • Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

Version Effective Date: 09/01/2019
Version Issued Date: 08/30/2019
Version Reissued Date: N/A



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