Preferred Physical Therapy Manual. An Independent Licensee of the Blue Cross and Blue Shield Association

Transcription

1 Preferred Physical Therapy Manual An Independent Licensee of the Blue Cross and Blue Shield Association

2 1 The Preferred Physical Therapist (PT) Network consists of therapists who have agreed to provide our members with quality services in an efficient and effective manner. A new physical therapist who joins the PT Network will be on a provisional status for two years in order to determine continued participation. The provider s National Provider Identifier (NPI) should be used when filing claims. Benefits for services for physical therapy are determined based on the member s contract benefit. For general information, refer to the Provider Manual. Covered Services For physical therapy to be medically necessary, it must be reasonable and necessary for the patient s diagnosis or treatment of the patient s condition. Medical necessity is indicated when: The diagnosis established by the physician or physician extender supports utilization of the therapy. There is documentation of objective physical and functional limitations [strength/range of motion (ROM)/mobility/activities of daily living (ADL) levels]. Therapy is provided until functional level for normal ADLs (may include modified return to work level) or plateau is reached but not necessarily back to pre-morbid functional status. There is a plan of care that includes treatment services that are expected to result in improvement of these limitations in a reasonable and generally predictable period of time. The amount, frequency and duration of the services must be reasonable. The services must be one-to-one. The services are skilled. These services must be of a level of complexity and sophistication, or the condition of the member must be such that the services required can be safely done and effectively performed only by a qualified physical therapist or under his/her supervision. Services such as the application of hot and cold packs, use of exercise equipment, and repetitive exercises do not ordinarily require the skills and full attention of a qualified physical therapist; therefore, they are not separately billable. If such treatments are given as a prerequisite to a skilled physical therapy procedure, they are considered part of that modality and are not separately billable.

3 Non-Covered Services Preferred PTs are responsible for notifying the patient of services that are not medically necessary for treatment of his/her condition. A Notification of Non-Covered Services statement can be used to explain to the member that he/she is responsible for these charges. The patient should sign the statement before the services are rendered. Be sure to keep the signed copy in the patient s medical record. Please refer to the Provider Manual on our website for details and examples. 2 Examples of Non-Covered Services: Treatments that do not have a physician referral (the initial evaluation visit does not require physician referral) Services considered a routine part of nursing care (e.g., turning patients to prevent pressure areas, walking patients to maintain mobility, routine dressing changes) Services that do not require the professional skills of a qualified physical therapist (e.g., hot packs/cold packs, except for instances of documented paresthesia, wounds) Repetitive services/treatments not requiring the skills of a physical therapist (e.g., general supervision of exercises previously taught to the member or caregiver, exercise equipment, Stairmaster, treadmill, bicycle) Group therapy Services related to activities for the general good and well being of patients such as general exercise to promote overall fitness and flexibility, and activities to provide diversion or general motivation Endurance enhancing activities Services provided when the patient s expected restoration potential is insignificant in relation to the extent and duration to the physical therapy services required to achieve such potential Passive exercises not related to restoring specific loss of function Maintenance care (e.g., lack of progress in restoring function/plateau) Remember: Blue Cross and Blue Shield of Alabama does not provide benefits for professional services of a physical therapist rendered to a member who is related to the physical therapist by blood or marriage or who lives in the provider s household. Covered Providers Licensed Physical Therapist PT students are covered providers when working under the direct on-site supervision of a Preferred PT. All treatment notes must be co-signed by the supervising Preferred PT. Services should be billed using the supervising physical therapist s NPI. Physical therapists with temporary licenses are covered providers when working under the direct on-site supervision of a Preferred PT. All treatment notes must be co-signed by the supervising Preferred PT. Services should be billed using the supervising physical therapist s NPI.

4 3 Licensed certified physical therapist assistants (PTA) are covered providers when working under the direction of a Preferred PT with the following provisions: The PT must interpret the physician s referral. The PT must perform the initial evaluation. The PT must develop the treatment plan and program, including long and short-term goals. The PT must identify and document precautions, special problems, contraindications, goals, anticipated progress and plans for re-evaluation. The PT must re-evaluate the patient and adjust the treatment plan as needed. The PT must perform the final evaluation and discharge planning. The PT must implement (perform the first treatment) and supervise the treatment program. The PT must co-sign each treatment note written by the PTA. The PT must indicate he/she has directed the care of the patient and agrees with the documentation as written by the PTA for each treatment note. The PT must render the hands-on treatment, write and sign the treatment note every sixth visit. Services should be billed using the supervising Preferred PT s NPI. Certified PTA students are covered providers when working under the direct on-site supervision of a Preferred PT or under the direct on-site supervision of a licensed PTA working under a Preferred PT. All treatment notes must be co-signed by the supervising Preferred PT. Services should be billed under the supervising PT s NPI. PTAs with temporary licenses are covered providers when working under the direct on-site supervision of a Preferred PT or under the direct on-site supervision of a licensed PTA with the approval of the supervising PT. All treatment notes must be co-signed by the supervising Preferred PT. Services should be filed using the supervising PT s NPI. Non-Covered Providers of Physical Therapy Services Athletic trainers, exercise physiologists, massage therapists, RNs, LPNs, certified strength trainers, secretaries, and office personnel are not considered covered providers. Services performed by these providers are not covered. For non-grandfathered plans, services provided by any provider acting within the scope of his/her license or certification will be covered. Filing for these kinds of services, as well as occupational and speech therapy services, under the Preferred PT s NPI is not acceptable and is not reimbursable.

5 Precertification Precertification requirements are determined first by the member s benefits. Second, if there are no benefit requirements for precertification or benefit limits, Preferred PT Network requirements apply. 4 Preferred PTs must submit precertification for physical therapy services rendered to a new patient beginning with the 16th visit. This process should be initiated prior to the 14th visit. If precertification is not obtained, all services associated with the 16th visit and subsequent visits will be non-covered and the patient will be held harmless. Patients may be billed if they have signed a non-covered services statement for each visit. The statement must indicate that the patient has been properly informed that the services to be rendered are not covered by Blue Cross and Blue Shield of Alabama and that the patient will be responsible for paying for the services. There are no retroactive certifications for these contracts. When filing a request for precertification, complete the appropriate Physical Therapy Precertification Form (which can be located on the Provider website) and submit it to: Blue Cross and Blue Shield of Alabama Fax Number: Attention: Physical Therapy Precertification If all requested information is not received, a determination will not be made. Urgent requests for initiation of therapy (which if not answered timely could jeopardize the health of the member) are due in 72 hours and non-urgent outpatient therapy review determinations are due within 7 days. Notification of the determination will be made by letter or fax. Note: Blue Advantage has a separate precertification form for therapy. Exceptions Precertification is not required for: Contracts that are secondary to Medicare or any other insurance carrier ITS Host and Federal Employee Plan (FEP) contracts Any contract with visit limits unless specifically noted to require precertification CPT Codes Listed below are a few of the Current Procedural Terminology (CPT) codes covered under the PT Network. Special care should be given in reporting and documenting these services Physical therapy evaluation Initial evaluation Physical therapy re-evaluation Re-evaluation is considered medically necessary when there is: an unanticipated change in patient status; a failure to respond to therapy interventions as expected; the need for a new care plan; additional injury; or an additional surgery. This code is not appropriate

6 5 for general status updates to physicians Application of a modality to 1 or more areas; hot or cold packs Application of hot or cold packs does not ordinarily require the skills, expertise, and full attention of a qualified therapist and are not separately billable Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercise to develop strength & endurance, range of motion & flexibility Documentation should indicate specific procedures, duration of time and response to treatment. Blue Cross only considers procedures medically necessary if a skilled licensed individual is needed to provide the service Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Therapeutic procedure, 1 or more areas, each 15 minutes, aquatic therapy with therapeutic exercises Additional information as indicated with CPT code applies Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) In order to be considered for coverage when billing therapeutic massage, the massage must be performed by a licensed physical therapist. Massage therapists, exercise physiologists, physician assistants, and office personnel are not considered as providers eligible for coverage. Therapeutic massage must be of a skilled nature and must be part of a specific, diagnosis-related goal. The services must be of a level of complexity and sophistication that they require the skills and expertise of a physician or physical therapist. Massages performed with hand-held devices such as vibrators are not considered skilled in nature and are not reimbursable Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes (Do not report CPT code in conjunction with CPT codes ) Treatment must be diagnosis-related and documentation must support proper billing of CPT code and contain the following: Description of specific area treated Soft tissue techniques performed Amount of time performing manual therapy

7 97530 Therapeutic activities, direct (one to one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Once the patient has been instructed and can safely and appropriately perform activities, the skill of a trained therapist is no longer considered medically necessary by Blue Cross. 6 Therapeutic massage must be of a skilled nature and must be part of a specific diagnosis related goal. The services must be of a level of complexity and sophistication that they require the skills and expertise of a physician or physical therapist. Massages performed with hand-held devices such as vibrators are not considered skilled in nature and are not reimbursable Debridement (e.g., high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (eg, fibrin devitalized epidermis and/or dermis, exudate, debris, biofilm) including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session; total wound(s) surface area; first 20 sq cm or less Each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure.) Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters Physical performance test or measurements (eg, musculoskeletal, functional capacity), with written report, each 15 minutes Blue Cross and Blue Shield of Alabama covers the initial two services of isokinetic testing for a comparison of the involved and uninvolved extremity. Follow-up testing may be billed monthly, if medically necessary. Only one service may be billed at the follow-up testing. Billing a service of each motion of a joint is not reimbursable. Billing for this code should include torque curves and other graphic reports with interpretation.

8 7 When Patients Should Be Discharged The patient is restored to normal ADL functioning level (may include modified work level). Reasonable goals have been achieved. There is no expectation of short term significant progress. The patient is unable to participate in the treatment program for medical, psychological or social reasons. The patient is non-compliant with treatment plans. Medical Record Documentation The medial record should include: Completed precertification form, if applicable Signed physician referral every four to six weeks Signature and credentials of the person performing the initial evaluation which includes: History Diagnosis Prior level of functioning Objective documentation including strength, ROM, levels or functioning and ADL Problems Goals related to problems Treatment plan including frequency and time frame Summary of objective/measurable data evaluating the progress towards goals (should be documented at least every four to six weeks) Progress notes referring back to goals and progress toward goals Daily treatment notes documenting modalities and procedures, written and signed with credentials by the person performing the hands-on treatment which include: Notes describing treatment given and the patient s response Written notes for each treatment and documentation for each charge Discharge summary including date of last visit, status, outcome of goals and home programming All submitted documentation including initial evaluation, plan of care, treatment notes, progress notes and discharge summaries must be written and signed by the person performing the hands-on treatment of the patient. Therapist codes and stamps are not acceptable. Credentials such as PT or PTA must accompany the signature. Unsigned notes and documentation will not be accepted. When submitting documentation for review of isokinetic/computerized strength testing and ROM testing, the computerized printout must be included. Appeals of Adverse Benefit Determinations One appeal, either expedited or standard, may be performed for medical necessity non-certification determinations.

9 Expedited Appeal An expedited appeal is available when there is an imminent or ongoing service requiring additional review of a non-certification determination. Appeal may be made by telephone, fax or and include additional information to be reviewed. Notification of the results of the appeal is made by telephone to the provider within 72 hours of receipt of the request with written notification to follow. 8 Standard Appeal A standard appeal, due to a decision not to certify additional visits, must be made in writing by mail or fax by the provider. Include the patient s medical record as needed for the review if not submitted previously to Blue Cross and Blue Shield of Alabama. Appeal requests should be mailed/faxed to: Blue Cross and Blue Shield of Alabama Post Office Box Birmingham, Alabama Fax Number: Telephone Number for Expedited Appeals: When requesting an appeal, additional information to support the medical necessity of the requested visits should be included. When a non-certification decision is made without a physician conversation, a peer-to-peer conversation may be requested by the ordering or supervising physician within three business days of the decision using the telephone number provided on the noncertification letter. If the original peer reviewer is not available, a peer alternate will be available to discuss the case. This does not count as an appeal. Any request beyond three business days of the decision is considered an appeal. Preferred Physical Therapists Audits A major strength of Blue Cross and Blue Shield of Alabama in managing healthcare costs is our ability to audit Preferred Providers and affect changes in utilization practice habits. Our contractual arrangements give us the right to audit medical records of patients of Preferred Physical Therapists in order to objectively evaluate the coding, billing and practice patterns, as well as the completeness of their medical records. An audit can be triggered by external referrals from members, group administrators, anonymous tips, and even other physical therapists that feel that a particular physical therapist, group or facility is not in compliance with the program guidelines. An audit may also be triggered from internal claims and precertification data also. If an offsite audit reveals unusual practice patterns or billing procedures that result in overpayments, refunds are required from the physical therapist and the amount is returned to the groups whose members were affected by the incorrect practices. Any physical therapist having an unsatisfactory audit must immediately correct any problems. A follow up audit will be performed to ensure that he/she is in compliance with the Preferred Physical Therapist guidelines. A second unsatisfactory audit can result in the therapist being removed from the Preferred Physical Therapy Program. These cases are referred to the Physical Therapist Advisory Committee for review. This committee is composed of five geographically distributed Preferred Physical Therapists. CPT codes, descriptions and other data only are copyrighted 2015 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.

10 An Independent Licensee of the Blue Cross and Blue Shield Association