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)