Outpatient Therapy 8/29/07 Complex Billing Workshop - Q and As

Outpatient Therapy 8/29/07 Complex Billing Workshop - Q and As Noridian Administrative Services, (NAS) LLC hosted a Complex Billing Outpatient Therapy Web based workshop on 8/29/07. Below are the questions and answers that resulted from this session: Q1. When counting Value Codes 50, 51 and 52 is that the calendar days of visits or number of therapies done? A1. The value codes are used to document the cumulative total visits completed since services were started through the billing period. The appropriate value codes are as follows: 50: for physical therapy visits 51: for occupational therapy visits 52: for speech therapy visits These codes would represent number of visits; not how many therapies are done that day. Reference: Ask The Contractor Q&As for 5/10/07 and the Medicare Claims Processing Manual, Chapter 5, Section 20.2(B). Q2. As a CORF, we have been asked frequently if a Physician Assistant or Nurse Practitioner can make a referral. We have always told them it must be an MD or DO. Is that correct? A2. Yes. The CORF services benefit does not recognize a nonphysician practitioner (NPP) for orders and certification. For Medicare purposes, the physician that orders and/or certifies the CORF services may be a doctor of medicine or osteopathy (including an osteopathic practitioner). The CORF physician or the referring physician must review the plan of treatment at least once every 60 days. Following the review, the physician must certify that the plan of treatment is being followed and that the patient is making progress in attaining the established skilled rehabilitation goals. Providers should be aware that CORF services must be furnished under a written plan of treatment that is established and signed by the physician who has recently evaluated the patient. It is expected, but not essential, that the physician will establish the plan in consultation with the physical therapists, occupational therapists, or speech-language pathologists who provide the actual therapy. The physician wholly establishes any respiratory therapy plan of care. Reference MBPM, Chapter 12, Section 30 and Chapter 15, Sections, 220.1.1, 220.1.2. Q3. If the physician fails to sign the re-certification, is it the physician or the therapist that is responsible for documenting the reason for the delay? A3. Providers should obtain the certification of the first interval of treatment as soon as possible after the plan of care is established. As soon as possible means that the physician/npp shall certify the plan as soon as it is obtained, or before the end of the first interval beginning at the initial therapy treatment (30 days for all outpatient rehabilitation providers except for CORF services which is a 60 day timeline). Recertifications that document the need for continued therapy in subsequent intervals should be signed before

or during the subsequent intervals of treatment. Subsequent recertifications should be completed before or during the next interval, unless they are delayed. Certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/npp makes a certification accompanied by a reason for the delay. Certifications are acceptable without justification for 30 days after they are due. Reference: Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3. Q4. Can an OPT provider set up and staff an outpatient PT dept in a nursing home and bill directly for those services, or do those services need to be billed by the nursing home? A4. Outpatient therapy providers may provide medically reasonable and necessary services to patients that are residing in skilled nursing facilities (SNFs) with one exception, Certified Outpatient Rehabilitation Facilities (CORFs) cannot provide these services. When therapy services are provided to a SNF patient, then the SNF must bill for both Part A and Part B residents when they are in a certified bed. If the patient is no longer skilled and is in a non-certified bed, then the therapy services may be billed by the entity that is providing the service. Q5. When we put the date of the updated Plan of Care onto the claim, we have been told that you want the date the therapist wrote the updated POC and signed it before sending it to the Doctor for signature, not the first day of the covered period. Is this correct? A5. Providers have two options for the dates related to occurrence codes 29 for physical therapy, 17 for occupational therapy, and 30 for speech-language pathology. The options are: a) This date can be the date that the initial plan of care was established by the therapist or physician OR ; b) This date can be the date that the plan of care was last reviewed and or updated by the therapist (or treating physician). Providers need to remember to update these occurrence code dates when a new episode of therapy services begins. The physician certification date is not required on the claim. A physician signature on an updated plan of care created or updated by the therapist is certification of the plan of care. While this documentation must be available in the case of medical review, it is not indicated on the claim itself. To clarify an additional billing scenario: A patient is attending physical therapy visits for treatment of condition A. The patient later develops an unrelated condition B and is referred for physical therapy treatment. From that point on, the patient receives physical therapy services for treatment of both condition A and B concurrently at the clinic. In this instance, the provider may choose to retain occurrence code 29 (for physical therapy services) as the date that the initial plan of care was initially established for the entire episode of care (which began with condition A) OR the provider may update occurrence code 29 as the date the most current POC was last reviewed/updated by the therapist or treating physician (which would involve condition B). Reference Medicare Claims Processing Manual, Chapter 5, Section 20 and Medicare Benefit Policy Manual, Chapter 15, Section 220(A), 220.1.2, 220.1.3.

Q6. Can the plan of care be signed by a PA or N.P? A6. In all outpatient therapy settings (with the exception of services provided in the CORF-see Q&A #2 above) a non-physician practitioner (NPP) may order, certify, and review therapy plans of care when state and local laws allow. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220(A). Q7. Is phonophoresis considered to be a covered service? A7. No. Currently, Noridian Administrative Services (NAS) does not cover phonophoresis, as there is insufficient scientific data, including evidence-based clinical studies, to support the benefits of the services. NAS recognizes that the application of this modality involves the use of ultrasound. When clinically indicated, the ultrasound component of this application may be reimbursable. In these instances, providers should bill for the ultrasound component using CPT 97035 (ultrasound). Any additional supplies/medications used during the application process are not reimbursable. This coverage clarification became effective for all NAS states (AK, AZ, ID, MN, MT, ND, SD, OR, UT, WA, WY) on 7/26/07. Q8. CMS does cover infrared except for certain codes. CMS does not categorically deny all infrared only those under certain ICD9 codes. Please address. A8. On October 24, 2006 the Centers for Medicare and Medicaid Services (CMS) published a National Coverage Determination (NCD) for Infrared Therapy Devices. This NCD states: The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. As a result of this NCD, Noridian Administrative Services (NAS) has reviewed the utilization of infrared treatment for other conditions. NAS will not reimburse for infrared used in the treatment of any clinical conditions as there is insufficient scientific data, including evidence-based clinical studies, to support the benefits of these services. NAS published this information in an article on 12/11/06. Reference Medicare National Coverage Determinations, Chapter 1, Part 4, Section 270.6. Q9. CPT code 97140 does say "manual lymphatic drainage" why can this not be used for lymphedema treatment? A9. Actual hands-on manual therapy techniques for manual lymphatic drainage (MLD) treatment are appropriately coded using the manual therapy code. However, services related to the application of elastic bandaging/wraps/stockings are not considered to be a covered skilled therapy service unless these services are provided as a component of medically reasonable and necessary patient and/or caregiver training for home management of the patient s condition. When patient and/or caregiver training is provided as part of the therapy visit and the time-based coding requirements are met, then the most appropriate physical medicine and rehabilitation code for home management training should be used for coding these additional lymphedema training services. It is not appropriate for therapists to bill for these services using an E/M code, unless there are

additional services that are provided to satisfy the entire descriptor for the E/M and physician incident-to requirements must also be satisfied. Reference Medicare National Coverage Determinations, Chapter 1, Part 4, Section 280.1. Q10. Can a COTA or PTA create short term goals and update them on the interval progress notes? A10. Since only long term goals are required in the plan of care, the Progress Report may be used to add, change or delete optional short term goals. Assistants may change goals only under the direction of a clinician. COTAs or PTAs may write elements of the Progress Report. However, reports that are written by assistants are not complete Progress Reports. The clinician must write a Progress Report during each Progress Report Period regardless of whether the assistant writes other reports. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220.1.2(B), 220.3(D). Q11. If a therapist is working with one patient and another one comes in and the therapist overlaps the patients, is it appropriate to bill the group code to each patient as well as the treatment modality that is being performed on each? A11. It would not be appropriate to bill both codes. The clinician must determine which type of treatment is actually being provided and bill only the appropriate code. When direct one-on-one patient contact is provided and time-based coding requirements are met, then the individual therapy code should be billed. These direct one-on-one minutes may occur continuously (15 minutes straight), or in notable episodes (for example, 10 minutes now, 5 minutes later). Each direct one-on-one episode, however, should be of a sufficient length of time to provide the appropriate skilled treatment in accordance with each patient s plan of care. Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, it is appropriate to bill each patient one unit of group therapy (untimed code). Providers should be aware that Medicare only reimburses for services provided by qualified professionals. Services provided by therapy aides are not reimbursable under Medicare. Reference The Centers For Medicare and Medicaid Services (CMS) Therapy Services FAQs and the Medicare Benefit Policy Manual, Chapter 15, Section 220(A), 230.1(B)(C), 230.2(B)(C), 230.3(B)(C). Q12. Can you touch on the guidelines for Line-of-site treatments for Medicare A patients? A12. Line-Of-Site treatment is terminology that providers commonly utilize for personal supervision level. Therefore, the answer relates to supervision levels. Supervision levels for outpatient rehabilitation therapy services are the same as those for diagnostic tests defined in 42CFR410.32. Depending on the setting, the levels include personal supervision (in the room), direct supervision (in the office suite), and general

supervision (physician/npp is available but not necessarily on the premises). Reference the Medicare Benefit Policy Manual, Chapter 15, Section 220. 42CFR410.32 excerpt: (i) General supervision means the procedure is furnished under the physician s overall direction and control, but the physician s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician. (ii) Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. (iii) Personal supervision means a physician must be in attendance in the room during the performance of the procedure. Q13. Lymphedema therapy includes both training/teaching AND intervention. When the therapist is providing intervention we have been coding 97140, but moving the edema out of the extremity is done by massage. Should the bill reflect this with those two codes? A13. This question is answered in #9 above. Q14. Can you tell us where the documentation is which notes that craniosacral therapy isn't covered? A14. In response to provider inquiries, Noridian Administrative Services (NAS) published an educational notice on 9/28/06 to clarify the coverage guidelines for craniosacral therapy. This coverage guideline was posted for the states that NAS had at that time which included MN, ND, AK, WA, ID, OR, UT and can be accessed via the NAS web site. The article was republished for all states on 7/26/07. Q15. Is an electronic signature OK on the original order for therapy? Also to sign the cert. every 30 days? A15. Signature means a legible identifier of any type (e.g., hand written, electronic, or signature stamp). Reference: Medicare Program Integrity Manual, Chapter 3, Section 3.4.1.1.(B) and Medicare Benefit Policy Manual, Chapter 15, Section 220(A). Q16. Transmittal 1019 (effective 1/1/07) conflicts with what was said regarding the "8 minute" rule. There is a specific example where it was appropriate to bill for LESS than 8 minutes of one CPT code. Please clarify. A16. The most current reference for The Centers For Medicare and Medicaid Services (CMS) regulations for calculating appropriate units for time-based code services are found in the Medicare Claims Processing Manual, Chapter 5, Section 20.2. This reference provides multiple examples for appropriate counting of time-based code minutes. Noridian Administrative Services (NAS) educates and reviews services based on these specific regulations. During a therapy visit when a patient receives:

33 minutes of therapeutic exercise (97110) 7 minutes of manual therapy (97140) 40 total time-based code minutes of treatment Then, appropriate billing of 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140. The eight minute rule simply states that: When only ONE service is provided in a day, providers should not bill for services performed for less than 8 minutes. Q17. When a patient is being seen for therapy at our facility during the month, and he is also seen for lab work or as an inpatient, which occurrence span codes are supposed to be used so that we don't get duplicate claim? A17. The 74 occurrence span code would be billed on the repetitive therapy claim with a date of the interruption of the service involved. Q18. Can a nurse practitioner or Physician assistant sign the Part A Medicare cert and recertification form by signed (one for initial, 14 day, 30 day, etc. form? A18. Non-physician practitioners (NPPs), i.e. nurse practitioners and physician assistants may certify for (Part b of A) outpatient therapy services, except when the services are provided in a Certified Outpatient Rehabilitation Facility (CORF) (see Q&A #2 and #3 above for further clarification). NPPs and physician assistants may also certify for (Part A) inpatient therapy services. Reference Medicare Benefit Policy Manual, Chapter 12, Section 30; Chapter 15, Section 220(A), 220.1.1-220.1.3. Q19. Can we bill for hot and cold packs or are they something that we can't even put on our claims? We have had conflicting information and we would like some clarification. Q19. Providers may bill for hot and cold packs. However, reimbursement for these services is bundled into other therapy modalities/procedures that are provided, usually but not necessarily, on the same date of service. Keep in mind that each of the services that are provided as part of the total treatment visit minutes should be reported in the medical record documentation. This information should be reported in a language that can be compared with the billing on the claim to verify correct coding for both timed and untimed code services. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220.3(E). Q20. If a patient is seen for a one time visit TENS application and instruction, should the visit be billed utilizing 97001 or 64550 or both? A20. The Centers for Medicare and Medicaid Services (CMS) requires physician certification for all reimbursable outpatient therapy services. Physician certification requires that therapy services be furnished under a plan of treatment. A plan of treatment cannot be developed until an evaluation and/or assessment has occurred. Based on this

reasoning, a therapy evaluation and plan of care must be developed in order to satisfy the CMS mandatory certification requirements for reimbursement. The application and instruction of Transcutaneous Electrical Nerve Stimulation (TENS) is considered to be a reimbursable treatment service. When coding and coverage requirements are met, then CPT 64550 may be appropriately used to describe this service. Q21. Do Additional Development Requests (ADRs) come by both mail and DDE or is it one or the other? A21. This is dependent on what state you are located in and how your facility was set up to receive ADRs from Noridian Administrative Services (NAS). If your facility is set up for DDE and is still receiving ADRs by paper, you may contact the Provider Contact Center at 1-877-908-8437 to have your DDE access updated to allow for accessing the ADRs using DDE. Q22. Where can I find a detailed/specific description of an outpatient Medicare B claim, 23x, and a detailed/specific description of an inpatient Medicare B claim, 22x? A22. At this time NAS has an example of a 22x claim that can be found in the Skilled Nursing Facility Manual at www.noridianmedicare.com Select applicable state Select Training Select on view all manuals Select Skilled Nursing Facility (SNF) pdf Q23. How do I access the remarks to show the outcome of a reviewed claim thru DDE - A23: Remarks in DDE can be found in page 4 of the claim. Q24. Are interval progress notes required for Medicare inpatients as well as outpatients? A24. Progress notes are an essential component of patient safety. All practitioners must be aware of all therapeutic interventions and interactions and the effect(s) of same in order to develop or amend their patient care plans. Moreover, documentation for all patients, regardless of whether or not they are inpatients, must support the ongoing need for skilled intervention. However, the therapy regulations for interval Progress Reports as stated in the Medicare Benefit Policy Manual, Chapter 15, Section 220.3(D) specifically pertain to services provided in outpatient therapy settings. Q25. What would be the correct billing for the following treatment: 7 minutes 97110, 6 minutes, 97530, and 7 minutes of 97116? Total time spent 20 minutes one billable unit but none meet the 8" rule. A25. 7 minutes therapeutic exercises (97110) 6 minutes therapeutic activities (97530) 7 minutes gait training (97116) 20 total time-based code treatment minutes

Appropriate billing for 20 minutes is 1 unit. The qualified professional shall select one appropriate CPT code to bill by comparing the time spent on 97110 and 97116 (7 minutes each) to 97530 (6 minutes) and bill one of the larger, which would be either 97110 or 97116. The 8 minute rule only applies when one service is provided on a single date of service and in that instance the provider should not bill for services that were performed for less than 8 minutes. The answers to other related examples may also be referenced in the Medicare Claims Processing Manual, Chapter 5, Section 20.2. Q26. Will you be having a similar seminar for part A inpatient billing? A26. The Center for Medicare and Medicaid Services (CMS) is working on finalizing new regulations for inpatient therapy billing. When these regulations finalize NAS would conduct training at that time. Q27. Clarification regarding the 700 and 701 forms, occurrence code 29 is the date of POC by the therapist, and then the update is the 30 day update from the PT and not the physician? A27. Answered in Q&A #5 above. Q28. Can we bill take home supplies with therapy? If so, how? We are using the take home supply rev code but it is being denied as provider liable instead of patient liable. A28. The cost of supplies (e.g. theraband, hand putty, electrodes) used in furnishing covered therapy care is included in the payment for the CPT/HCPCS codes that are billed, and are, therefore, not separately billable. Reference Medicare Benefit Policy Manual, Chapter 15, Section 230.1(C). Q29. How do we bill driving evals, noncovered? Do we add the GY/GA/GZ modifier? A29. There is no benefit category for driving evaluations. Since there is no benefit category, driving evaluations may never be covered by Medicare and the provider does not need to bill this service to Medicare. If the provider does bill the service, no Advance Beneficiary Notice (ABN) is required, the beneficiary is liable for the charges. However, courtesy suggests providing a Notice of Exclusion from Medicare Benefits (NEMB) to the patient and is strongly encouraged. Information about the NEMB and a template may be accessed at www.cms.hhs.gov/medicare/bni/. Providers should place occurrence code 21 on the claim when billing for denial. If the beneficiary has requested a demand bill, the provider should bill the claim with the occurrence code 20 and the GY modifier. Reference Social Security Act (SSA) 1862(a)(1)(A); Medicare Claims Processing Manual, Chapter 1, Section 60. Q30. We are a Skilled Nursing Facility and a Long Term Care Facility, all of our beds are certified. Can we bill Part B therapy services for residents in a certified bed but are not under skilled services? A30. SNFs are responsible to bill for all therapy services for Part A and B residents when they are in a certified bed. Even if the patient is not at a skilled level of care the SNF is the entity that must bill for these services. If the patient was no longer at a skilled level of care and was moved to a non-certified bed in the facility then the entity providing the therapy may bill for these services.

Q31. Are SLPA's guidelines the same as PTA's & COTA's? A31. No. Services of speech-language pathology assistants are not recognized for Medicare coverage. Services provided by speech-language pathology assistants, even if they are licensed to provide services in their states, will be considered unskilled services and denied as not reasonable and necessary if they are billed as therapy services. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220(A), 230.3. Q32. In regards to the interval progress notes: Can a PTA or COTA complete these? A32. COTAs or PTAs may write elements of the Progress Report. However, reports that are written by assistants are not complete Progress Reports. The clinician must write a Progress Report during each Progress Report Period regardless of whether the assistant writes other reports. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220.3(D). Q33. What would be the correct billing for the following treatment: 7 minutes 97110, 6 minutes, 97530, and 7 minutes of 97116? Total time spent 20 minutes one billable unit but none meet the 8" rule. A33: See Q&A #25 above. Q34. What is the difference between repetitive and non-repetitive services? A34. Repetitive Part B services furnished to a single individual by providers that bill FIs shall be billed monthly (or at the conclusion of treatment). The instructions in this subsection also apply to hospice services billed under Part A, though they do not apply to home health services. Consolidating repetitive services into a single monthly claim reduces CMS processing costs for relatively small claims and in instances where bills are held for monthly review. Services repeated over a span of time and billed with the following revenue codes are defined as repetitive services: Type of Service Revenue Code(s) DME Rental 0290 0299 Respiratory Therapy 0410, 0412, 0419 Physical Therapy 0420 0429 Occupational Therapy 0430 0439 Speech-Language Pathology 0440 0449 Skilled Nursing 0550 0559 Kidney Dialysis Treatments 0820 0859 This information is found in the Claim Processing Manual, Chapter 1, Section 50.2.2. Q35. Can you explain modifier 59? A35. Under certain circumstances, facilities may need to indicate that a procedure was distinct or independent from other services provided on that same date, and modifier - 59 may be appropriate depending on the circumstances. Modifier -59 is used to identify procedures that are not normally reported together. These procedures must be clearly separately identifiable and documentation must support appropriate use of this modifier.

Q36. For a wound care evaluation, if you do debridement also, can you bill evaluation and debridement? A36. The Centers for Medicare and Medicaid Services (CMS) requires physician certification for all reimbursable outpatient therapy services. Physician certification requires that therapy services be furnished under a plan of treatment. A plan of treatment cannot be developed until an evaluation and/or assessment has occurred. Based on this reasoning, a therapy evaluation and plan of care must be completed in order to satisfy CMS s mandatory certification requirements for reimbursement. When a separately identifiable medically necessary wound care assessment is completed by the therapist (on the same day or on a different day from the initial therapy evaluation), then it would be considered to be a reimbursable service when documentation supports medical necessity of the service and that each of the CPT coding descriptor requirements are met. Providers should be aware that the Active Wound Care Management codes each require that some type of skilled debridement or negative pressure wound therapy treatment must be provided for these codes to be billable outpatient therapy services. Q37. Our old FI - CAHABA instructed us that it was acceptable to bill one unit of 97140 when placing lymphedema bandages on a patient. Your webcast states that this is in error. What is the correct code to use for 8-15 minutes of placing bandages on a lymphedematous limb (this is a highly skilled service that requires the skills of a therapist). A37. See Q&A #9 above. Q38. Do you have an example of what the MD should document for delayed cert? A38. There is no specific format that must be followed for meeting this documentation requirement. The Centers for Medicare and Medicaid Services (CMS) regulation states that: Certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/npp makes a certification accompanied by a reason for the delay. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3(D). Q39. Does a patient have to sign a form for the provider to send in an appeal on behalf of the patient? A39. Provider can send in appeal requests on behalf of the patient and will not need to have the patient sign forms authorizing the provider to do that appeal. This is referenced in Change Request 3530. Q40. If the patient is seen one time for an Evaluation and we know it will be a one time visit, do we still need the initial plan of care certified? A40. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. When an evaluation is the only service provided by a provider in an episode of treatment, the evaluation serves as the plan of care if it contains all of the required information. When an evaluation is the only service provided, then a referral/order and evaluation are the only required documentation. If the

patient presented for evaluation without a referral or order and does not require treatment, then a physician referral/order or certification of the evaluation is required for payment of the evaluation. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220.1.3, 220.3(C). Q41. If there is not a valid CPT code for the therapist to bill when providing edema wrapping, can a therapist bill an E/M service? What are our options for edema wrapping? A41. See Q&A #9 above. Q42. Some clarification on what is included in a Maintenance Program. Specifically, if a patient needs to be treated for obesity and Medicare does not cover obesity (unless the obesity is due to an illness or disease)..can we see the patient for an evaluation to set them up on a maintenance program? Does that include any follow-up visits? A42. Medicare does not reimburse for services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services for Medicare purposes. Medicare does not reimburse for services related to general endurance training or fitness programs. Medicare will only reimburse for services that are medically reasonable and necessary for the treatment of an illness. When the medical necessity requirements are met, Medicare will reimburse for the establishment of a maintenance program along with any additional necessary updates to that program. If the patient does not meet Medicare s medical necessity standard, then services related to the maintenance program would not be reimbursable. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220.2 Q43. Are we required to bill Medicare for non-covered services, i.e. hearing aides, therapy supplies, etc? A43. Providers are not required to bill Medicare for non-covered services. See Q&A #28 above for further clarification. Q44. Can providers give an ABN for non-covered iontophoresis and phonophoresis services? A44. Yes. Iontophoresis and phonophoresis are not considered to be medically reasonable and necessary as there is insufficient scientific data, including evidence-based clinical studies, to support the benefits of these services. When an Advance Beneficiary Notice (ABN) is not provided to the patient, then the services must be billed as noncovered services using the GZ modifier. However, if a timely and appropriate ABN is provided, then the services may be billed as covered services using the GA modifier. Occurrence code 32 must also be placed on the claim with the date the ABN was issued. Reference Social Security Act (SSA) 1862(a)(1)(A); Medicare Claims Processing Manual, Chapter 1, Section 60. Q45. Does fluidotherapy require constant attendance for it to be billable? A45. Fluidotherapy is a high intensity heat modality consisting of dry finely divided particles suspended in a heated air stream. The use of fluidized therapy dry heat is an

acceptable alternative to other heat therapy treatments. CPT 97039 should be used when billing fluidotherapy. Constant attendance, unless dictated by specific clinical conditions, is not a requirement for billing this modality. Q46. Why was the BTE Technologies equipment not included in the list for non-covered therapy services? A46. This Q&A is to inform providers of non-covered outpatient therapy services that Noridian Administrative Services (NAS) has noted as billed in error through Medical Review. Currently, NAS does not cover services provided using BTE Technologies rehabilitation equipment, as there is insufficient scientific data, including evidence-based clinical studies, to support the benefits of these services. Please note that the published listing of non-covered therapy services is not intended to be all inclusive. Q47. Should we bill group therapy for dovetailing concurrent services? A47. See Q&A #11 above. Q48. Do the services listed on the non-covered services slide apply for inpatient therapy services too? A48. This Therapy Web Ex was specific only to therapy services that are provided in the outpatient therapy setting. Although this therapy web-ex was prepared and addressed for outpatient services, the non-covered services indicated on the presentation are not covered in any setting. Q49. When the patient is seen in the acute care hospital as an observation (outpatient) and is discharged with instructions to follow-up with the outpatient therapy clinic for needed rehabilitation, can we charge for a re-evaluation? A49. For Medicare purposes a new evaluation must be medically reasonable and necessary or may be the result of the patient being seen in a 'new setting', i.e. moving from an inpatient to an outpatient setting. Since observation services are outpatient services, an additional therapy evaluation and a plan of care developed in the outpatient setting would not typically be reimbursable without justification. Examples of potential justifications may be: a) Patient has experienced a significant change in his/her condition or functional status; b) The outpatient clinic therapist determines that additional tests and measures are necessary. Keep in mind that the physician must certify the need for any therapy treatment services that are provided under a therapy plan of care. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220, 220.3. Q50. We provide crutch training in a hospital setting. We have completed a therapy evaluation, plan of care, and have received physician certification for these therapy services. Is it okay for us to bill CPT 97116 x 2 for these services? A50. Billing for crutch training should occur only rarely since the skills of a therapist are rarely necessary. In the event that such skills are required, the PT or OT must have a Plan of Care (POC) certified by a physician as medically necessary and documentation must demonstrate that PT or OT skills are required.

Q51. NAS stated that CPT 97140 was not appropriate for PROM, AROM, manual stretching activities, so what is? A51. The following CPT codes are subject to time-based coding requirements for billing and require direct contact by the health care provider. 97110 (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility). This code is appropriate for exercises such as: a) passive or active stretching activities; b) passive, active assistive, or active range of motion exercises (PROM, AAROM, AROM); and c) strengthening exercises using manual resistance, theraband, or using other types of appropriately applied resistance equipment. 97124 (Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion). This code is appropriate for hands-on techniques as stated in the CPT definition and to soften scar tissue. Also, the tapotement techniques described may be appropriate for mobilization of mucous secretions in the lungs. 97140 (Manual therapy techniques e.g., mobilization/manipulation, manual lymphatic drainage, manual traction, one or more regions, each 15 minutes). This code is appropriate for hands-on techniques as stated in the CPT definition and for soft tissue or joint mobilization. Please note, this code should not be used when providing the following: a) manual stretching (see CPT 97110) or b) massage, tapotement and/or percussion (see CPT 97124). Also note that NAS has determined that the efficacy of craniosacral therapy has not been clearly demonstrated in the peerreviewed literature. Medicare cannot reimburse craniosacral therapy until clinical efficacy has been established. This therapy does not meet Medicare s reasonable and necessary standard as referenced in the Social Security Act (SSA) 1862(a)(1)(A). Refer to the Noridian Administrative Services (NAS) article on Craniosacral Therapy for further information. Q52. When a patient that I am seeing becomes ill, is it okay for me to place them on hold and resume treatment in 1-2 weeks? A52. When a patient suffers a short-term illness during an episode of therapy services, it may be reasonable to place the patient s treatment on hold until they are able to return to complete the therapy services. Providers should be aware that the same time interval requirements for interval Progress Notes and physician certifications do not change while the patient s therapy services are on hold. When a patient suffers a more serious long-term illness during an episode of therapy services, then it may be reasonable to discharge the patient from skilled care until they are able to participate. Upon resumption of care, the patient may qualify for the establishment of a new therapy evaluation and plan of care. Provider discretion should be used for each clinical scenario with the clinician s rationale clearly described in the medical record. Q53. A therapy re-evaluation may be necessary at the time of patient discharge. Why isn t it always reimbursable?

A53. Re-evaluations provide additional objective information that is not included in other documentation. Re-evaluations are separately payable and are 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 for that interval. If the patient s progression with the therapy services was anticipated in the plan of care, then additional re-evaluation services would not typically be medically reasonable and necessary. A discharge note is required for each episode of treatment. However, this note is not reimbursable as a re-evaluation, unless the medical record documentation supports that the additional evaluative service that is provided was medically reasonable and necessary for the treatment of this patient s condition. Routine assessments of expected progression in accordance with the plan of care are not considered to be reimbursable as re-evaluation services and should not be billed using these codes. Reference Medicare Benefit Policy Manual, Chapter 15, Section 220(A), 220.3(D).