An Update on Outpatient Therapy Services

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1 An Update on Outpatient Therapy Services The Centers for Medicare & Medicaid Services (CMS) recently issued a Medicare Learning Network (MLN) Matters article listing the therapy codes for calendar year (CY) Specifically, CMS has updated the therapy codes list by adding Healthcare Common Procedure Coding System/ Current Procedure Terminology 2010 Edition (HCPCS/CPT) code (Larngeal function studies) and deleting HCPCS/CPT code (Standard Canalith reposition procedures). CMS also requested that Medicare contractors offer compliance education to providers on outpatient therapy services. In line with this recommendation, this article aims to provide an overview on correct billing and coding practices for outpatient therapy services. What are therapy services and who can bill for these services? According to CMS, therapy services include physical therapy, occupational therapy, and speech language pathology services. Under section 1834(k)(5) of the Social Security Act, a uniform coding system is required for all outpatient rehabilitation therapy services and comprehensive outpatient rehabilitation facility services. CMS uses the HCPCS/CPT as the coding system to report these services. The following providers are required to bill their Medicare contractor for outpatient rehabilitation services using the HCPCS/CPT coding system: o Comprehensive outpatient rehabilitation facilities; o Home health agencies; o Non physician practitioners (e.g. nurse practitioners and clinical nurse specialists) who are performing services within their State scope of practice; o Occupational therapists in private practice o Other rehabilitation facilities; o Physical therapists in private practices; o Physicians (including MDs, DOs, podiatrists, and optometrists); o Providers of outpatient physical therapy and speech language pathology servicesproviders; o Skilled nursing facilities; o Speech language pathologists in private practices; and o Hospitals (only for outpatients and inpatients that are not in a covered Part A stay). What are the therapy codes and where can I find them? As noted above, CMS updated the therapy code list for CY The updated therapy code list went into effect January 1, 2010 and is posted below. The list is also located on CMS website at: Management Systems, Inc. and Atlantic Information Services, Inc.*, th Street, NW, Suite 300, Washington, *Atlantic Information Services is a publishing and information company that has been serving the health care industry for more than 20 years. It develops highly targeted news, data and strategic information for managers in hospitals, health plans, medical group practices, pharmaceutical companies and other health care organizations. AIS products include print and electronic newsletters, Web sites, looseleafs, books, strategic reports, databases, audioconferences and live conferences.

2 2 Table 1: 2010 Therapy Code List HCPCS/CPT Effective Date Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ /1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ /1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/06

3 3 HCPCS/CPT Effective Date Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ Prior to 1/ /1/ /1/ /1/ Prior to 1/06 G0281 Prior to 1/06 G0283 Prior to 1/06 G0329 Prior to 1/ T 1/1/ T 1/1/2009

4 4 What are the coding and billing issues with therapy services? There are several coding and billing issues related to therapy services. These issues may include (1) failure to report therapy modifiers GN, GO, and GP; (2) compliance with the therapy cap and modifier KX; (3) failure to accurately report timed and untimed codes; (4) accurately coding sometimes therapy codes; and (5) documentation issues (e.g. plan of care). Therapy Modifiers GN, GO, and GP CMS requires providers to use specific modifiers when reporting HCPCS/CPT therapy codes. Specifically, providers must append one of the following modifiers when appropriate: Modifier GN for speech language pathology; Modifier GO for occupational therapy; and Modifier GP for physical therapy. Failure to report the modifier can result in the return of the claim to the provider. Further, CMS notes that [m]odifiers GN, GO, and GP refer only to services provided under plan of care for physical therapy, occupational therapy and speech language pathology services [and] should never be used with codes that are that are not applicable on the list of applicable therapy services. For example, HCPCS/CPT codes 95861, 95863, 95869, 95870, 95900, 95903, 95904, and are not therapy services. Instead they are diagnostic services and should not include the aforementioned therapy modifiers. Therapy Cap and Modifier KX The Balanced Budget Act of 1997 sets an annual therapy cap for Medicare Part B beneficiaries. The financial limits are applied to outpatient physical therapy, occupational therapy, and speech language pathology services in all provider settings with the exception of outpatient hospitals and hospital emergency room (types of bill 12X, 13X, or 85X). CMS recently announced the therapy caps for CY The annual limits for CY 2010 are as follows: Physical therapy and speech language pathology services combined: $1860 Occupational therapy services: $1860 The limits are based on applicable deductible, coinsurance, and incurred expenses. Moreover, under the Deficit Reduction Act of 2005, Congress directed CMS to develop an exception process for outpatient therapy caps. Usually, when an exception to therapy caps exists, modifier KX is used. However, the exceptions to outpatient therapy caps expired on December 31, As a result, outpatient therapy service providers should not submit claims with the KX modifier for services furnished on or after January 1, It should be noted that if a beneficiary has reached his/her outpatient therapy service limit(s), therapy services may be provided if they are medically necessary and furnished by the outpatient department of a hospital. However, if the therapy services are rendered outside the outpatient department of a hospital and the beneficiary has exceeded the therapy cap(s), then therapy services are not covered and the provider may charge the beneficiary for the services. 1 Part A Outpatient Therapy Cap Exception Process. TrailBlazer Health Enterprises. January 2010.

5 5 Timed and Untimed Codes CMS defines untimed code as HCPCS/CPT codes where the procedure is not defined by a specific timeframe. If a provider rendered a procedure that is an untimed HCPCS/CPT code, the provider should enter 1 in the field label units. For example, HCPCS/CPT code (speech/hearing evaluation) is an untimed code. Since it is an untimed code, the number of minutes spent on providing the speech or hearing evaluation is irrelevant for coding and billing purposes. Rather, providers should focus on the number of units, which is one, given that is an untimed code. In contrast, a timed code such as (therapeutic activities, direct (one on one) patient contact by the provider, each 15 minutes), includes a timeframe in its definition. Therefore, if a beneficiary receives 60 minutes of direct one on one therapeutic activities, four units should be reported on the claim. Sometimes Therapy Codes According to CMS, sometimes therapies are defined as therapy services that are performed by an individual without a certified therapy plan of care. This is different from always therapy services where a qualified therapist renders therapy services under a certified plan of care. In CY 2010, the sometimes therapy HCPCS/CPT codes include 92520, 97597, 97598, 97602, 97605, 97606, and 0183T. Under the Outpatient Prospective Payment System (OPPS), a separate payment is provided for certain services designated as sometimes therapy services if these services are furnished to hospital outpatients as non therapy service, that is, without a certified therapy plan of care. 2 In order to be paid under the OPPS for non therapy services furnished to hospital outpatients, providers should avoid: Appending therapy modifier GP, GO, or GN to the sometimes therapy HCPCS/CPT code; and Reporting therapy revenue code 042X, 043X, or 044X with sometimes therapy HCPCS/CPT code. Plan of Care According to CMS Medicare Benefit Policy Manual, Chapter 15 section 220.2(b), a plan of care should contain the following elements: Diagnosis; Long term treatment goals; Type of therapy services; Amount of therapy services(number of times in a day the type of treatment is provided); Duration of therapy services (number of weeks, or number of treatment session); and Frequency of therapy services (number of times a week the type of treatment is provided). A plan of care may be certified by a physician or NPP and the format of the certification may be in a variety of forms. Examples may include a physician s progress note, physician s or NPP s order, or a plan of care plan that is signed and dated by the physician or NPP. Overall, providers must ensure that all contents and approvals of the plan of care are fulfilled in order to submit claims with HCPCS/CPT codes that require a certified plan of care. 2 January 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS). MLN Matters: MM6751 Revised. 22 Dec

6 6 Are there special rules for hospitals? In the Medicare Benefits Manual Chapter (B), CMS outlines special provisions for hospitals. Several of these provisions address how a hospital may bill Medicare for outpatient therapy services that are furnished under arrangement or off site (e.g. in a skilled nursing facility, outpatient rehabilitation facility, home). The following list highlights CMS policy. Services rendered directly or under arrangement. Hospitals are permitted to bill Medicare for outpatient therapy services rendered directly or under arrangement in the hospital s outpatient department. The services must be medically necessary and the hospitals should use bill type 13X or 85X when reporting these services. Services rendered in a home. In the event a beneficiary is registered as an outpatient for a hospital and is unable to come to the hospital for medical reasons, the hospital may send its therapists to the beneficiary s home. Similar to above, the services must be medically necessary and the bill type 13X or 85X should be used. Services rendered in a skilled nursing facility (SNF). Hospitals are permitted to send its therapists to a SNF if: (1) the beneficiary is residing in a non certified section of the SNF or in another residential setting; (2) the services are medically necessary; and (3) meet the outpatient therapy services requirements. Services rendered in an outpatient rehabilitation facility or private practice. Hospitals may make arrangements with an outpatient rehabilitation facility or another entity (e.g. private practice) to provide therapy services if the beneficiary is registered as an outpatient for the hospital. The services must comply with federal regulations and hospitals should use bill type 13X or 85X. Although, CMS permits hospitals to bill Medicare for therapy services as services of the hospital in certain circumstances, there are settings where it is not permitted. For example, a hospital cannot send its therapist to an inpatient rehabilitation facility or a long term care facility and bill Medicare for therapy services of the hospital. The services rendered in the inpatient rehabilitation facility or the longterm care facility would be subject to the prospective payment system applicable to the facility and should not be billed separately. Moreover, a hospital is not permitted to send its therapist to provide therapy services to beneficiaries receiving services from a home health agency under a home health plan. Similar to inpatient facilities, the therapy services are bundled in the Medicare payment to the home health agency and thus not separately billable. What is next? Overall, CMS encourages providers to remain updated with Medicare s coding and billing policies related to outpatient therapy services. CMS notes in its correspondence that provider s Medicare contractors are the best source of answer to specific Medicare questions. Thus, providers should contact their contractor when difficulties in coding and billing arise. Official Sources CMS, Medicare Benefit Manual, CMS , Ch. 15, sec (B), Contents of Plan. CMS, Medicare Benefit Manual, CMS , Ch. 15, sec (A) method and Disposition of Certification. CMS, Medicare Benefits Manual, CMS , Ch.15, sec (B), Special Rules for Hospitals. CMS, Medicare Claims Processing Manual, CMS , Ch. 5, sec. 10 Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services.

7 7 CMS, Medicare Claims Processing Manual, CMS , Ch. 5, sec. 20 HCPCS Coding Requirement Annual Update to the Therapy Code List. MLN Matters: MM Dec Annual Update to the Therapy Code List JA6719. MLN Provider Inquiry Assistance: JA Dec January 2010 Update of the Hospital Outpatient Prospective Payment System (OPPS). MLN Matters: MM6751 Revised. 22 Dec Therapy Cap Values for Calendar Year (CY) MLN Matters: MM6660 Revised. 17 Nov Therapy Cap Values for Calendar Year (CY) 2010 JA660. MLN Provider Inquiry Assistance: JA Nov Medical Record Documentation Tips. TrailBlazer Health Enterprises. June Part A Outpatient Therapy Cap Exception Process. TrailBlazer Health Enterprises. January 2010.

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