Rehabilitation Guidelines:

Ø  Physicians/NPPs, independent physical therapists, and independent occupational therapists may bill for physical therapy services using the CPT physical medicine and rehabilitation codes

Ø  When both PM&R services and evaluation service are reported on the same date of service, the evaluation may be reimbursed if the evaluation is clearly and separately documented. 

Ø  Reevaluation services reported on a routine basis with each PM&R treatment session may be subject to review.

Ø  List the appropriate ICD-10 code that best supports the medical necessity for the service.

Ø  PT/OT services, performed by a qualified professional in independent practice employed by a physician/NPP or physician/NPP group with a Medicare NPI, should be reported to Medicare, with an appropriate HCPCS/CPT code and the appropriate therapy modifier (GN, GO, GP).

Documentation Guidelines

– Report the patient’s specific condition for which the current therapy episode of care services is being performed in the first position in Item 21 of the CMS1500 claim form or electronic format equivalent field.

–  Report existing conditions, complexities, or circumstances influencing the length or intensity of the current therapy episode of care in the remaining positions.  

–  When physical medicine and rehabilitation services are performed for beneficiaries who have suffered musculoskeletal or neurological complications secondary to some other disease, use the ICD-9-CM code for the sign/symptom/complication diagnosis.

–   The underlying condition may also be coded, but is not required. However, the underlying, causal pathological condition alone will not be sufficient for coverage.

Rehabilitation Codes:

• When reporting time units for treatments, report each 15 minutes as one (1) unit.  Do not report the actual time of the treatment in the quantity/units field. 
• The PM&R codes should not be reported multiple times per day when the same codes are used for treatment of multiple body areas, the time units should be combined for same treatment to multiple body areas.   

CERTIFICATION

ü  Certification is the physician’s/no physician practitioner’s (NPP) approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.

Outpatient Therapy

• For the purposes of therapy policy, an outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that discipline in that setting.
• During the episode, the beneficiary may be treated for more than one condition; including conditions with an onset after the episode has begun.

EVALUATION:

• Evaluation is a separately payable comprehensive service provided by a clinician, that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities.

RE-EVALUATION

• Provides additional objective information not included in other documentation.
• Re-evaluation is separately payable and is periodically indicated during an episode of care when the professional assessment of a clinician indicates a significant improvement, or decline, or change in the patient’s condition or functional status that was not anticipated in the plan of care.
• The decision to provide a re-evaluation shall be made by a clinician. 

Non-Covered Services:

• PM&R services subject to ANY annual financial limitation, or claims not reported with modifiers GN, GO, or GP will be denied as processable. 
• Services exceeding the OT/PT Rehab. Financial Limit will be denied as non-covered. 4
• .PM&R services are not covered when the certification/recertification is not performed by the attending physician/NPP every 90 days.   5
• Topical medication used with Iontophoresis is a Medicare excluded service and will be denied as non-covered
• This section excludes routine physical examinations and services. 7.
• PM&R services performed or ordered/referred by chiropractors and doctors of dental medicine/surgery will be denied as not-covered.   8.
• Chiropractic manipulations performed by physical therapists will be denied as non-covered.  
• PM&R services performed on a random basis, for the good and welfare of the patient do not meet the conditions for payment and will be denied as not covered. 10.
• PM&R services performed without the establishment of a plan of care do not meet the conditions for payment and will be denied as not covered.

Modifiers:

• GO – Service Delivered Under an Outpatient Occupational Therapy Plan of Care
• GP – Service Delivered Under an Outpatient Physical Therapy Plan of Care
• GY- Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit
• GN: Services delivered under an outpatient speech language pathology plan of care