Chapter
30
Physical Medicine and Rehabilitation
30.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-2 30.2 Benefits, Limitations, and Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-2 30.2.1 Osteopathic Manipulative Treatment (OMT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-2 30.2.2 Physical Medicine, Physical Therapy (PT), and Occupational Therapy (OT) . . . 30-3 30.2.2.1 Authorization Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-4 30.3 Coordination with the Public School System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-6 30.4 Claims Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-7 30.5 Reimbursement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-7 30.6 TMHP-CSHCN Services Program Contact Center. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-7
CPT only copyright 2011 American Medical Association. All rights reserved.
30
CSHCN Services Program Provider Manual–November 2012
30.1 Enrollment To enroll in the CSHCN Services Program, physical medicine and rehabilitation providers must be actively enrolled in Texas Medicaid, have a valid Provider Agreement with the CSHCN Services Program, have completed the CSHCN Services Program enrollment process, and comply with all applicable state laws and requirements. Out-of-state physical medicine and rehabilitation providers must meet all these conditions, and be located in the United States, within 50 miles of the Texas state border, and be approved by the Department of State Health Services (DSHS). Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC §371.1617(6) for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC §38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, “Provider Enrollment,” on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures.
30.2 Benefits, Limitations, and Authorization Requirements Osteopathic manipulative treatment (OMT), physical therapy (PT), and occupational therapy (OT) are benefits of the CSHCN Services Program when medically necessary and appropriate. A physician or podiatrist (for conditions below the ankle) must prescribe PT and OT services that are provided through or in a rehabilitation center, a licensed hospital, a physician’s office, or the office of an enrolled PT or OT provider. Only licensed therapists may provide PT and OT services. The CSHCN Services Program reimburses therapists and outpatient facilities based on the procedure codes listed in this chapter. Therapy sessions include the time span the therapist is with the client, time spent preparing the client for the session, and the time spent completing documentation.
30.2.1 Osteopathic Manipulative Treatment (OMT) OMT is a form of manual treatment to eliminate or alleviate somatic dysfunction and related disorders. This treatment may be accomplished by a variety of techniques. OMT may be considered for reimbursement by the CSHCN Services Program in the following situations: • Acute musculoskeletal condition • Acute exacerbation of a chronic condition • Acute treatment pre- or postsurgery that is directly related to the surgery An acute phase is defined as a period of time up to 180 days from the start date of therapy. The acute AT modifier must be submitted with the claim for reimbursement. The AT modifier is described as “treatment provided for an acute condition.” Procedure codes 98925, 98926, 98927, 98928, and 98929 must be used when billing for OMT. The modifier AT must be submitted with the claim for OMT. 30–2
CPT only copyright 2011 American Medical Association. All rights reserved.
Physical Medicine and Rehabilitation
If a physician submits an initial or subsequent care inpatient visit with the same date of service as an OMT procedure code, both are considered for reimbursement.
30.2.2 Physical Medicine, Physical Therapy (PT), and Occupational Therapy (OT) Physical medicine is the use of one or more modalities to produce therapeutic changes to biologic tissue. It includes, but is not limited to, thermal, acoustic, light, mechanical, or electric energy. Physical medicine may be provided by physicians, podiatrists (for services below the ankle), licensed physical therapists, or licensed occupational therapists under the direction of a physician. The CSHCN Services Program may reimburse for physical medicine under the following conditions: • The client has a disability requiring therapy to improve or maintain function, range of motion, strength, or to prevent or decrease the risk of deformity or osteoporosis. • The client has an exacerbation of chronic illness or condition (e.g., juvenile rheumatoid arthritis [JRA], hemophilia, or sickle cell crisis). • The client has sustained a traumatic injury or is experiencing late effects of a traumatic injury requiring therapy to restore or maintain function, range of motion, strength, or to prevent or decrease the risk of deformity or osteoporosis. • The client requires short-term therapy related to surgery or casting. • The client or family requires training on the use of equipment, orthotics, or prosthetics. • The client or family requires instruction in activities for daily living specific to their home environment. • The client requires an assessment for appropriate equipment, seating, braces, orthotics, or prosthetics. Providers must use the following procedure codes for authorization and for claim submission when billing for physical medicine services: Procedure Codes S8990 92526
97001
97002
97003
97004
97012
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97530
97535
97537
97542
97750
97755
97760
97761
97762
97799
30
The following procedure codes are billed in 15-minute increments. Providers should not bill for services performed less than 8 minutes. Treatment procedure codes are limited to 1 hour of physical therapy and 1 hour of occupational therapy on the same day, any provider, with GP or GO modifiers. Procedure Codes S8990 92526
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97139
97140
97150
97530
97535
97537
97542
97750
97755
97760
97761
97762
97799
CPT only copyright 2011 American Medical Association. All rights reserved.
30–3
CSHCN Services Program Provider Manual–November 2012
The following procedure codes are not payable in 15-minute increments and are limited to a quantity of once per day, per distinct therapy type (physical or occupational): Procedure Codes 97012 97016 97026
97018
97022
97024
97028
Physical therapists must use procedure code 97001 for evaluation and procedure code 97002 for reevaluation. Occupational therapists must use procedure code 97003 for evaluation and procedure code 97004 for reevaluation. These codes do not require modifiers. Reimbursement of an evaluation (procedure codes 97001 and 97003) is limited to once every 180 days to the same provider. Reimbursement for reevaluation (procedure codes 97002 and 97004) is limited to once per 30 days to the same provider. Evaluation and reevaluation may be considered on appeal with supporting documentation that a comprehensive reevaluation and assessment was provided by a different provider. Evaluation and reevaluation procedure codes are comprehensive codes. Physical therapy treatment will be denied when billed by any provider on the same day as physical evaluation or reevaluation. Occupational therapy treatment will be denied when billed by any provider on the same day as occupational evaluation or reevaluation. Procedure codes 97750 and 97760 are comprehensive codes and include an office visit. Providers are not reimbursed for an office visit with the same date of service as procedure codes 97750 and 97760. Procedure codes 97010, 97014, 97545, and 97546 are not benefits of the CSHCN Services Program.
30.2.2.1 Authorization Requirements PT and OT evaluations and reevaluations do not require authorization. All other PT and OT services require authorization. Initial therapy service authorization requests may not be authorized for longer than 6 months. Authorization requests for an extension require documentation of medical necessity. The following documentation must be submitted with the authorization request form for consideration for authorization: • A CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1) form or CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2) form must be submitted prior to the start of care for the current episode of therapy. • Modifiers are required on all authorization requests for PT services (modifier GP) or OT services (modifier GO). • The most recent evaluation and treatment plan, including: • Documented age of the child. • Diagnosis. • Description of specific therapy being prescribed. • Specific treatment goals. • Anticipated measurable progress toward goals. • Duration and frequency of therapy. • Requested dates of service. New requests for additional therapy must include documentation of all progress made from the beginning of the previous treatment period. PT and OT may be authorized if the child meets one of the following guidelines: • The child is younger than 3 years of age, and measurable progress toward individual treatment goals can reasonably be expected (this may not always indicate physical improvement in the client’s condition). 30–4
CPT only copyright 2011 American Medical Association. All rights reserved.
Physical Medicine and Rehabilitation
• The child is 3 years of age or older, not presently eligible for or receiving special education or special services during the school year, and has a disabling condition requiring therapy services where measurable progress toward individual treatment goals can reasonably be expected (this may not always indicate physical improvement in the client’s condition). In addition, the child also must have at least one of the following conditions: • The child has a developmental anomaly including, but not limited to, cerebral palsy, spina bifida, arthrogryposis, reduction deformities of a limb, hydrocephalus, Erbs palsy (brachial plexus palsy), or encephalocele. • The child has an acute episode of a chronic condition that may include, but is not limited to, JRA, hemophilia, lupus erythematosus, sickle cell crisis (joint pain, swelling, and limited range of motion), or cancer. • The child presents a new condition that may include, but is not limited to: • Upper extremity trauma, median or radial nerve lesions, late effects of fractures, burns, spinal cord injury, traumatic brain injury, cerebral embolism, brain tumor, or Guillain-Barré Syndrome. • The child is seen in a specialty clinic for periodic assessment or reevaluations. • The child needs short-term therapy related to surgery or casting. • The child requires training on the use of equipment such as wheelchairs (powered or manual), orthotics or prosthetics, or other equipment such as ambulation aids like walkers or crutches). • Short-term assistance is required to instruct the child/family in activities of daily living specific to the home or environment (bathing, toileting, or making equipment assessment for braces, wheelchairs, cushions, and so on). PT or OT services may be authorized as follows: • For children from birth to 3 years of age with a developmental anomaly, therapy services may be authorized up to two times a week for 6 months (may be extended up to school eligibility without medical review). Requests for a higher frequency of visits per week require the submission of documentation of medical necessity. • Children who are 3 through 21 years of age with a developmental anomaly should be referred to the public school system for services unless they are ineligible or there is a medically related therapy issue to address. • Presurgical therapy related to the reason for surgery may be approved up to three times a week for 1 month. • Postsurgical therapy directly related to the reason for surgery or for cast removal may be authorized up to five times a week for 2 months and post rhizotomy for up to three times a week for 1 year. After these specified time periods, extensions require documentation of medical necessity. • Therapy addressing an acute episode of a chronic condition (seldom eligible for therapy through the school system) may be authorized up to five times a week for 3 months. After 3 months, the physician’s documentation of a continued acute episode is required. After the first 6 months are authorized, documentation of the specific rationale for the need of continued therapy based on the client’s chronic diagnosis must be submitted. • New conditions such as upper extremity trauma, median or radial nerve lesions, or late effects of fractures, may have therapy authorized up to five times a week for 3 months. Extensions after 6 months require additional documentation of medical necessity. • New conditions such as third-degree burns, spinal cord injury, traumatic brain injury, cerebral embolism, brain tumor, or Guillain-Barré Syndrome may have therapy authorized for up to five times a week for 3 months and may be extended up to 1 year. After 1 year, documentation of the specific rationale of the need for continued therapy must be submitted. • Home program monitoring for clients from birth to 3 years of age with cerebral palsy, spina bifida, arthrogryposis, reduction deformities of limbs, or hydrocephalus may be authorized for up to two times a month for 6 months.
CPT only copyright 2011 American Medical Association. All rights reserved.
30
30–5
CSHCN Services Program Provider Manual–November 2012
• Home program monitoring for clients from birth to 21 years of age with JRA, hemophilia, lupus erythematosus, and sickle cell crisis (joint pain/swelling and limited range of motion) may be approved for up to once a month for 6 months. Extensions may be allowed at up to 6-month intervals with medical justification. • Activities of daily living instructions to teach clients, parents, and caregivers for clients 3 years of age through 21 years of age may be authorized up to three times a week for 1 month. Extensions may be allowed at up to 6-month intervals with justification. • One equipment assessment before receiving the equipment and one assessment after receiving the equipment may be authorized. • Training in the use of manual wheelchairs may be authorized for up to five times a week for 1 month. • Training in the use of powered wheelchairs may be authorized for up to five times a week for 1 month and then three times a week for 2 months. • Training in the use of orthoses/prostheses (braces/artificial limbs) may be authorized for up to five times a week for 1 month and then three times a week for 2 months. Requests for additional training require documentation of the specific rationale for the medical need. • Reciprocating gait orthoses (RGOs) may be provided for children with spina bifida or similar functional disability. The required documentation includes: • A statement from the physician indicating the medical necessity. • A coordinated PT treatment plan. • Documentation that the client/family is expected to comply with the treatment plan. • Dynamic splints are provided on a case-by-case basis using the following criteria submitted by the physician: • The client’s condition to be treated with the dynamic splint • The client’s current course of therapy to date for the condition to be treated • The rationale for the use of the dynamic splint at this time • A therapy treatment plan related to the dynamic splint • Training for other equipment (such as walkers or crutches) may be authorized for up to five times a week for 1 month. Refer to: Section 4.2, “Authorizations,” on page 4-3 for detailed information about authorization requirements. Appendix B,“CSHCN Services Program Authorization Request for Initial Outpatient Therapy (TP1),” on page B-104 or Appendix B,“CSHCN Services Program Authorization Request for Extension of Outpatient Therapy (TP2),” on page B-100. Note: Fax transmittal confirmations are not accepted as proof of timely authorization submission. Note: A physician’s prescription is considered current when it is signed and dated within 60 days before the start of therapy. A prescription is valid for 6 months.
30.3 Coordination with the Public School System Clients may receive therapy services from both the CSHCN Services Program and school districts only when the therapy provided by the CSHCN Services Program addresses different client needs. If the client is of school age, therapy provided through the CSHCN Services Program is not intended to duplicate, replace, or supplement services that are the legal responsibility of other entities or institutions. The CSHCN Services Program encourages the private therapist to coordinate with other therapy providers to avoid treatment plans that might compromise the client’s ability to progress.
30–6
CPT only copyright 2011 American Medical Association. All rights reserved.
Physical Medicine and Rehabilitation
30.4 Claims Information To be considered for reimbursement, claims must identify the specific therapy type. Claims for PT services must include modifier GP, and claims for OT services must include modifier GO. Evaluation and reevaluation procedure codes do not require the modifiers. Outpatient therapy services provided by a physical or occupational therapist or by an outpatient facility must be submitted to TMHP in an approved electronic format or on a CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as TMHP does not key any information from claim attachments. Superbills, or itemized statements, are not accepted as claim supplements. The Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes included in policy are subject to National Correct Coding Initiative (NCCI) relationships. Exceptions to NCCI code relationships that may be noted in CSHCN Services Program medical policy are no longer valid. Providers should refer to the Centers for Medicare & Medicaid Services (CMS) NCCI web page at www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html for correct coding guidelines and specific applicable code combinations. In instances when CSHCN Services Program medical policy quantity limitations are more restrictive than NCCI Medically Unlikely Edits (MUE) guidance, medical policy prevails. Note: NCCI guidelines do not apply to therapy procedure codes if a valid prior authorization number is submitted on the claim. Refer to: Chapter 39, “TMHP Electronic Data Interchange (EDI),” on page 39-1 for information about electronic claims submissions. Chapter 5, “Claims Filing, Third-Party Resources, and Reimbursement,” on page 5-1 for general information about claims filing. Section 5.7.2.4, “CMS-1500 Paper Claim Form Instructions,” on page 5-27 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.
30.5 Reimbursement 30
Physicians, podiatrists, nurse practitioners (NPs), clinical nurse specialists (CNSs), and occupational or physical therapists may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. Outpatient hospital facilities may be reimbursed 80 percent of the rate allowed by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), which is equivalent to the hospital’s Medicaid interim rate. The CSHCN Services Program implemented rate reductions for certain services. The OFL includes a column titled “Adjusted Fee” to display the individual fees with all percentage reductions applied. Additional information about rate changes is available on the TMHP website at www.tmhp.com/pages/topics/rates.aspx. Note: Certain rate reductions including, but not limited to, reductions by place of service, client type program, or provider specialty may not be reflected in the Adjusted Fee column.
30.6 TMHP-CSHCN Services Program Contact Center The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community.
CPT only copyright 2011 American Medical Association. All rights reserved.
30–7
CSHCN Services Program Provider Manual–November 2012
30–8
CPT only copyright 2011 American Medical Association. All rights reserved.
