How to submit claims for physician or NP or Physical or Occupational Therapist (PT or OT) or Speech-Language Pathologist (SLP) - In therapy billing

For claims submitted by a physician or NPP:

•    Services performed by non-employees or those not under a physician’s or NPP’s direct supervision are not covered. 

•    Services not relating to a written treatment plan are not medically necessary. 

•    Services that do not require the professional skills of a physician or NPP to perform or supervise are not medically necessary.

For claims submitted by a Physical or Occupational Therapist (PT or OT) or Speech-Language Pathologist (SLP) in independent practice: 

•    An order, sometimes called a referral, for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. 

•    Claims submitted by anyone other than a therapist enrolled as a Medicare provider are not covered. 

•    Services not performed by or under the direct supervision of the therapist are not covered. 

•    Services performed by people who are not employees of the therapist are not covered. 

•    Services not furnished in the therapist’s office or in the patient’s home are not covered.

•    Physical therapy services that do not require the professional skills of a qualified PT to perform or supervise are not medically necessary. 

•    Occupational therapy services that do not require the professional skills of a qualified OT to perform or supervise are not medically necessary.

•    Speech-language pathology services that do not require the professional skills of a qualified SLP to perform or supervise are not medically necessary.

Maintenance Therapy

Maintenance therapy after therapeutic goals and/or rehabilitative potentials are reached is medically reasonable and necessary but is not covered. However, a qualified professional may develop a maintenance program for the patient to pursue outside of a therapy program and plan of care, generally administered and supervised by family or caregivers. Periodic evaluations of the patient’s condition and response to treatment may be covered when medically necessary if the judgment and skills of a qualified professional are required. Examples include:

•    Design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease.

•    Instructing the patient, family member(s) or caregiver(s) in carrying out the maintenance program. 

•    Infrequent re-evaluations required to assess the patient’s condition and adjust the program.

If a maintenance program is not established until after the therapy program has been completed (and the skills of a therapist are not necessary), development of a maintenance program is not considered reasonable and necessary for the patient’s condition. 

Note: Bill these services (e.g., codes 99212, 99213, 99214, 99215, 97002, 97004) with the appropriate evaluation/re-evaluation. It is expected these services will be infrequently required.

General Modality Guidelines (Codes 97012, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039)

THERAPY SERVICES (PT, OT, SLP) (L32710)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

The cornerstones of rehabilitative therapy are mobilization, education and therapeutic exercise. The goal of rehabilitative medicine is discernible, functional progress toward the restoration or maximization of impaired neuromuscular and musculoskeletal function. To that end, the dynamic component of therapy, mobilization and patient education should predominate. Passive modalities should be used in the “warm-up” phase of the patient encounter as preparation for or as an adjunct to therapeutic procedures, and in the “cool-down” phase for reduction of pain, swelling and other post-treatment syndromes. Though passive modalities may predominate in the earlier phases of rehabilitation where the patient’s ability to participate in therapeutic exercise is restricted, Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care. Further, Medicare expects the patient’s record to clearly reflect medical necessity for passive modalities, especially those that exceed 25 percent of the cumulative service hours of rehabilitative therapy provided for any beneficiary under a plan of care. 

Complicating factors that may influence treatment, e.g., they may influence the type, frequency and/or duration of treatment, may be represented by diagnoses by patient factors such as age, severity, acuity, multiple conditions, co-morbidities, and motivation; or by the patient’s social circumstances, such as the support of a significant other or the availability of transportation to therapy. 

In more refractory cases, the practitioner will support the need for continued care with documentation that clearly outlines the factors that affect the rate of recovery and reinforces the anticipation that further functional gain is expected. The contractor recognizes variability in strength, recovery time and the ability to be educated, and allows for a recertification for additional therapy, as long as adequate medical documentation by the supervising physician or therapist is recorded in the medical record and the patient continues to demonstrate progress. 

In all cases, whether the duration and intensity of rehabilitative services rendered are limited or extensive, Medicare expects the patient’s medical record to clearly demonstrate medical reasonableness and necessity for all therapy services, both active and passive. If an individual’s expected rehabilitation potential is insignificant, or the patient’s maximum rehabilitation potential have been realized, therapy is not reasonable and necessary and should not be reported to Medicare as a payable service.

Though this LCD establishes limitations to duration and intensity of outpatient rehabilitation, Medicare expects that most patients will not require maximum numbers of services. Providing maximal services as a routine is of concern and will result in Medicare auditing. 

Evaluation and Management CPT code list

Evaluation and Management (E&M) codes are to be performed by physicians, nurse practitioners and physician assistants. Physician codes should be billed using the rendering provider’s individual NPI.

99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a problem focused history; a problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s)

are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.

Billing Instructions: Bill 1 unit per visit.

99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.

Billing Instructions: Bill 1 unit per visit.

99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity.

Typically, 30 minutes are spent face-to-face with the patient and/or family. Billing Instructions: Bill 1 unit per visit.

99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.

Billing Instructions: Bill 1 unit per visit.

Medicare Provider Enrollment and Claim Submission - Basic information

Provider Enrollment

The provider enrollment process is a critical function that assures only qualified and eligible providers are enrolled in the Medicare program. Physicians and non-physician practitioners (NPPs) who provide services to Medicare beneficiaries must enroll as Medicare providers to receive reimbursement for services.

Providers must choose one of the options below to enroll:

• Complete appropriate CMS-855 enrollment application

• Provider Enrollment, Chain and Ownership System (PECOS)

All providers billing to Medicare must have a National Provider Identifier (NPI). The NPI is a unique, 10-digit identification number for covered health care providers. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) states covered providers must share their NPI with other providers, health plans, clearinghouses, or any other entity that may need it for billing purposes.

You can apply for an NPI through the National Plan and Provider Enumeration System (NPPES). The NPI must be obtained prior to submitting an initial application to Medicare. It is required on all CMS enrollment applications.

PECOS is a national, Internet-based database that supports the provider enrollment function. This database is used to store and verify provider information, add new providers, or make changes to existing Medicare providers during the enrollment process. 

PECOS can be used for the following:

• Initial Medicare enrollment

• View, change, or track enrollment

• Add or change a reassignment of benefits

• Revise existing Medicare enrollment information

• Reactivate an existing enrollment record

• Withdraw from Medicare

• Submit a Change of Ownership (CHOW)

All things you need to know about LCD, - FAQ

What is the difference between LCDs and NCDs?

A. Local coverage determinations (LCDs) for a specific jurisdiction are developed by the Medicare Administrative Contractor (MAC) assigned to that jurisdiction. First Coast Service Options Inc. is the MAC for Florida, Puerto Rico, and the U.S. Virgin Islands. Although the majority of coverage determinations are local, in certain cases, Medicare may develop a national coverage determination (NCD) that is applicable to all jurisdictions.

: Where can I find LCDs on Fist Coast Service Options Inc.’s Medicare provider website?

A. Although the Centers for Medicare & Medicaid Services’ (CMS) Medicare coverage database (MCD) still holds the “official versions” of local coverage determinations (LCD), identical copies are now hosted in First Coast’s own coverage database, which may be accessed through First Coast’s LCD lookup.

The LCD lookup tool helps you find the coverage information you need quickly and easily by utilizing the preferences (line of business and geographic location) that you indicated upon entry onto First Coast’s Medicare provider website. Its intuitive “form interface” also makes it easy to use. Just enter a procedure code or “L number,” click the corresponding button, and the application will automatically display links to any LCDs applicable to the parameters specified.

Click the link, and you can view the entire LCD (except attachments) and quickly find the information you need. Best of all, depending upon the speed of your Internet connection, the LCD search process can be completed in less than 10 seconds. And if you’re looking for fee schedule information as well as coverage information, you can search for both simultaneously by using of First Coast’s fee schedule lookup.

Observation CPT code 99233, 99234, 99235 and 99236

99233

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components: a detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

Billing Instructions: Bill 1 unit per visit.

99234 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) requiring admission are of low severity. Typically, 40 minutes are spent at the bedside and on the patient's hospital floor or unit.

Billing Instructions: Bill 1 unit per visit.

99235 Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit. Billing Instructions: Bill 1 unit per visit.

CPT code 82270 - 82274

Medicare Coverage of Ultrasound Screening for Abdominal Aortic Aneurysms 

(AAA) and Screening Fecal-Occult Blood Tests (FOBT) 82270-82274

Provider Types Affected

This MLN Matters Article is intended for physicians, physician assistants, nurse practitioners and clinical nurse specialists submitting claims to Medicare Administrative Contractors (MACs) for ultrasound screening for Abdominal Aortic Aneurysms (AAA) and Screening fecal-occult blood tests (FOBT) ordered for Medicare beneficiaries.

Provider Action Needed

Effective for dates for service on and after January 27, 2014, MACs shall pay claims for ultrasound screening for AAA and screening FOBTs per the modified requirements in 42 CFR 410.19 and 410.37. See the details of the changes in the Background section below. Make sure that your billing staffs are aware of these changes.

Background

Medicare Part B coverage of screening FOBTs and ultrasound screening for AAA is covered for certain beneficiaries that meet eligibility requirements as described in regulations. As part of the CY 2014 Physician Fee Schedule rule, the Centers for Medicare & Medicaid Services (CMS) revised he Medicare Part B coverage requirements for Ultrasound Screening for AAA (42 CFR 410.19) and Screening FOBT (42 CFR 410.37).

Evaluation Management - Prepayment review for CPT codes 99223 and 99233

First Coast Service Options Inc. (First Coast) recently conducted data analysis due to the high comprehensive error rate testing (CERT) error rates for evaluation and management services pertaining to Current Procedural Terminology®(CPT®) codes 99223(initial hospital visit) and 99233(subsequent hospital visit). The CERT November 2014 forecasting report indicates a projected error rate of 39.8 percent for CPT®code 99223 and a projected error rate of 34.4 perc for CPT®code 99233. The data indicates that the specialty of internal medicine is the primary contributor to the CERT error rate: internal medicine error rates are currently trending at 36.6 percent for CPT®code 99233 and 33.3 percent for CPT®code 99223.

Documentation requirements

The American Medical Association (AMA) CPT®manual defines code 99223as follows:

Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: 

 A comprehensive history;§

 A comprehensive examination; and§

 Medical decision making of high complexity§ 

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. 

Usually, the problem(s) requiring an admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient’s hospital unit. 

The AMA CPT®manual defines code 99233 as follows:

Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: 

 A detailed interval history ;§

 A detailed examination;§

 Medical decision making of high complexity§ 

Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family needs.