LCD/NCD Portal

L32807

 

THERAPY SERVICES BILLED BY PHYSICIANS/NONPHYSICIAN PRACTITIONERS

 

10/09/2012

 

Indications and Limitations of Coverage and/or Medical Necessity

• Therapy services have their own benefit under §1861of the Social Security Act and shall be covered when provided according to the standards and conditions of the benefit described in Medicare manuals.

o Statute 1862 (a) (20) of the Act requires that payment be made for a therapy service billed by a physician/NPP only if the service meets the standards and conditions – other than licensing – that would apply to a therapist.

• The intent of this Local Coverage Determination (LCD) is to address specific issues identified through medical record review when therapy services are billed by Physicians/Nonphysician practitioners (NPPs).

o This LCD is not intended to provide a comprehensive or all inclusive listing of all Medicare coverage and billing requirements.

o Providers who decide to provide therapy services and bill those services to Medicare (therapists and physicians/NPPs), must comply with all requirements outlined in the Social Security Act, Medicare manuals including Pub. 100-02, Chapter 15, Sections 220-230 and the LCD titled Therapy and Rehabilitation Services.

 

Indications

• Though passive modalities may predominate in the earlier phases of rehabilitation where the patient’s ability to participate in therapeutic exercise may be restricted, Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care.

• Further, Medicare expects the patient’s record to clearly indicate medical necessity for passive modalities.

• Covered physical therapy services must relate directly and specifically to an active written treatment plan established by the physician/NPP and must be reasonable and necessary to the treatment of the individual’s illness or injury.

o The plan (also known as a plan of care or plan of treatment) must be established before treatment is begun.

o The plan is established when it is developed (e.g., written or dictated).

o The plan must address the condition for which physical/occupational therapy is an accepted method of treatment as defined by standards of medical, physical therapy and occupational therapy practice standards and relate directly to the written treatment plan.

o The plan of treatment should address specific therapeutic goals for which modalities and procedures are outlined in the terms of type, frequency and duration. Therapeutic short and long term goals must be individualized to the patient and must be measurable.

o The patient’s functional limitations are documented in terms that are objective and measurable.

o There must be an expectation that the condition or level of function will improve within a reasonable (and generally predictable) time.

o The signature and professional identity of the person who established the plan, and the date it was established must be recorded within the plan. If someone other than the physician creates the plan, the physician/NPP must certify the plan within the required timeframes (see Documentation Requirements and refer to Pub. 100-02, Chapter 15, Sections 220-230 for complete treatment plan and documentation requirements).

 

Limitations

• Physical therapy services consisting of the performance of routine packages of adjunctive passive therapy services (e.g., electrical stimulation, ultrasound and whirlpool), that do not include modalities aimed at restoring physical function are not covered.

o Adjunctive passive therapy modalities (e.g., electrical stimulation, whirlpool) are considered therapy services and must be performed by a qualified individual.

• Physical therapy is not covered when documentation indicates the patient has not reached therapy goals and is not making significant improvement or progress, and/or is unable to participate and/or benefit from skilled intervention, or the patient refuses to participate.

• Physical therapy is not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of a physical/occupational therapist. (e.g., temporary weakness which may follow a brief period of bed rest following abdominal surgery).

• It is not medically necessary for a qualified professional to perform or supervise maintenance programs that do not require the professional skills of a qualified therapist.

• These situations include:

o Services related to activities for the general good and welfare of patients (i.e., general exercises to promote overall fitness and flexibility)

o Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients.

o Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities.

o Maintenance therapies after patient has achieved therapeutic goals or for patients who show no further meaningful progress and should become patient- or caregiver-directed.

o Enhancing already evident/existing functional status (i.e. basic activities of daily living) is not reasonable and necessary and therefore noncovered.

• Medicare is authorized to pay only for services provided by those trained specifically in physical therapy, occupational therapy or speech-language pathology.

o That means that the services of athletic trainers, massage therapists, recreational therapists, kinesiotherapists, low vision specialists or any other profession may not be billed as covered therapy services.

 

Medicare only covers therapy services when personally performed by one of the following:

• Licensed therapy professionals: licensed physical therapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs)

• Licensed physical therapy assistants when supervised directly by a licensed PT (direct supervision requires the PT to be present in the office suite at the time therapy is rendered).

• Licensed occupational therapy assistants when supervised directly by a licensed OT (direct supervision requires the OT to be present in the office suite at the time therapy is rendered).

• Medical Doctors (MDs) and Doctors of Osteopathy (DOs)

• Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.

• Qualified Nonphysician Practitioners (NPP) including Physician Assistants (PA), Clinical Nurse Specialists (CNS) or Nurse Practitioners (NPs) when performing services within their licenses’ scope of practice and their training and competency.

• “Qualified” personnel when allowed under state law if directly supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met (incident to requires the physician to be present in the office suite during the time therapy is rendered).

o See Pub. 100-02, Chapter 15, Section 60.1 for requirements related to “incident to” services.

o Qualified personnel is defined as an individual who may or may not be licensed as a therapist but meets all of the requirements of a therapist with the exception of licensure (i.e., has completed educational requirements but has not obtained licensure – see Pub 100-02, Chapter 15. Section 230.5 for complete requirements regarding qualified personnel).

o Therefore, services performed by a Physical Therapy Assistant (PTA) or Occupational Therapy Assistant (OTA) are never covered “incident to” a physician/NPP.

o If a physician employs a PT or OT, the therapist can enroll in Medicare and re-assign benefits to the group.

o Services performed by a PTA/OTA under the direct supervision of the PT/OT, can then be billed to Medicare if the services are billed under the PT/OT’s performing provider number.

• Please note that for therapy services performed by anyone other than individuals meeting the requirements above, the services are not covered and must not be reported to Medicare for payment.

*Refer to the LCD titled Therapy and Rehabilitation Services for specific indications and limitations for individual therapy modalities.

 

 

Documentation Requirements

 

• Documentation fully supporting the medical necessity should be maintained in the patient’s medical record and made available to Medicare upon request.

• Therapy services shall be payable when the medical record and the information on the claim form consistently and accurately report covered therapy services.

o Documentation must be legible, relevant and sufficient to justify the services billed.

o In general, services must be covered therapy services provided according to the requirements in Medicare Manuals.

o Medicare requires that the services billed be supported by documentation that justifies payment.

o Documentation must comply with all legal/regulatory requirements applicable to Medicare claims.

• The initial evaluation identifies the problem or difficulty the patient is having which helps determine the appropriate therapy necessary to treat the patient.

o An evaluation is a comprehensive service requiring professional skills to make clinical judgments about conditions for which services are indicated.

o If a new diagnosis/problem is encountered, then an additional evaluation may be appropriate to determine what course of treatment is necessary for the separate identifiable diagnosis/problem.

• Therapy services must relate directly and specifically to a written treatment plan.

o The plan (also known as a plan of care or plan of treatment) must be established before treatment is started.

o The plan is established when it is developed (e.g., written or dictated).

o The signature and professional identity of the person who established the plan, and the date it was established must be recorded within the plan.

o The plan of care shall be consistent with the related evaluation, which may be attached and is considered incorporated into the plan.

o The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources.

o Long Term treatment goals should be developed for the entire episode of care and not only for the services provided under a plan for one interval of care in the current setting.

o When the episode of care is anticipated to be long enough to require more than one certification, the long term goals may be specific to the part of the episode that is being certified.

o  Goals should be measurable and pertain to identified functional impairments.

• Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time or the need to establish a safe and effective maintenance program.

o Evaluation, re-evaluation and assessment documented in Progress Notes should describe objective measurements that, when compared, show improvement in function or decrease in severity or rationalization for an optimistic outlook to justify continued treatment.

• All qualified professionals rendering therapy must document

o the appropriate history,

o examination,

o diagnosis,

o functional assessment,

o type of treatment,

o the body areas to be treated,

o the date therapy was initiated, and

o expected frequency and

o Number of treatments.

• Daily treatment notes must indicate the individual modalities performed that day.

o Although not a requirement that the minutes must be documented for each modality representing a time-based code, the billing and total time code treatment minutes must be consistent.

• The treatment notes must clearly indicate who performed the therapy and their credentials.

• A separate justification statement may be included either as a separate document or within the other documents if the provider/supplier wishes to assure the contractor understands the reasoning for services that are more extensive than is typical for the condition treated.

o A separate statement is not required if the record justifies treatment without further explanation.

o If the patient is expected to exceed the therapy cap, the record must clearly indicate the medical necessity for the patient to receive covered services above the cap.

• In addition to the plan of care, other relevant documentation may include medical history, physical examination (s), and results of pertinent diagnostic tests or procedures.

• Documentation should include objective measurements, and a statement regarding where the patient is towards meeting established goals in the plan of care. Results of one of the following four measurements are recommended:

o National Outcomes Measurement System (NOMS) by the American Speech-Language Hearing Association.

o Patient Inquiry by Focus on Therapeutic Outcomes, Inc. (FOTO).

o Activity Measure – Post Acute Care (AM-PAC).

o OPTIMAL by Cedaron through the American Physical Therapy Association.

o Note: If results of one of the four instruments listed above are not recorded, the medical record shall contain that information outlined in Pub.100-02, Chapter 15, Section 220.3.C.

• The medical record must identify the physician responsible for the general medical care.

o Outpatient therapy MUST be under the care of a Physician/NPP.

 An order (sometimes called a referral) for therapy service, documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician.

 Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.

• Certification is the physician’s/NPP’s approval of the plan of care.

o Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care.

o A certification is timely when it is obtained within 30 calendar days of the initial treatment under that plan of care.

• Recertification must be obtained within the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whichever is less.

• Treatment notes and progress reports should be entered into the record within 1 week of the last date to which the Progress Report or Treatment Note refers.

o For example, if treatment began on the first of the month at a frequency of twice a week, a Progress Report would be required at the end of the month.

• The Progress Report that describes a month of treatment must be dated not more than 1 week after the end of the month described in the report.

• When both a modality/procedure and an evaluation service are billed, the evaluation may be reimbursed if the medical necessity for the evaluation is clearly documented.

• When therapy services are billed as incident to a physician/NPP services, the requirement for direct supervision by the physician/NPP and other “incident to” requirements must be met, even though the service is provided by a licensed therapist who may perform the services unsupervised in other settings.

• Documentation supporting the medical necessity for multiple heating modalities (e.g., CPT codes 97018, 97022, 97024, 97034, 97035, 97036) on the same date of service must be available for review and demonstrate the medical necessity for the restoration of function in the individual patient.

• For certain therapy services that require direct (one-on-one) patient contact by the provider (e.g. 97032: Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes), these services should only be billed if the therapist/physician/NPP is personally performing the service for the duration of the treatment.

o In this regard, for electrical stimulation (CPT code 97032) if the therapist/physician/NPP is only placing the electrodes on the patient and setting the machine and leaving the room, the appropriate codes to bill would be HCPCS codes G0281 and G0283 (electrical stimulation, [unattended]).

 

Treatment Logic

• Physical therapy and rehabilitative services are prescribed treatment plans generally provided to improve, restore and/or compensate for loss or impaired physical function resulting from disease, injury, or a surgical procedure.

• The goal of rehabilitative medicine is a return to the highest level of function realistically attainable and within the context of the disability through the use of therapeutic exercise, education and mobilization.

• The foundation for recovery is therapeutic exercise, education and mobilization thus adjunctive passive modalities should be used in the “warm-up” phase of the patient encounter as preparation for or as an addition to therapeutic procedures, and in the “cool-down” phase for reduction of pain, swelling and other post-treatment syndromes.

 

Sources of Information and Basis for Decision

 

American Physical Therapy Association. (2011). Defining medically necessary physical therapy services. Retrieved from http://www.apta.org/Payment/PrivateInsurance/DefiningMedicallyNecessary/

 

CMS Internet-Only Manual (IOM), Pub. 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4 (Physicians Certifications and Recertification of Services), Section 50

 

CMS Internet-Only Manual (IOM), Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 (Covered Medical and Other Health Services), Sections 60.1 and 220-230

 

CMS Internet-Only Manual (IOM), Pub. 100-08, Medicare Program Integrity Manual, Chapter 13, Section 13.1.3

 

 

10/09/2012

The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

 

 CMS LCD L32807 Therapy Services billed by Physicians/Nonphysician Practitioners