Outpatient Rehab Facility (ORF) Physical Therapy - Service Specific Post-Payment Final Findings - JE Part A

The certification requires a qualified physician or nonphysician practitioner (NPP) signature and date on the plan of care or some other document to indicate approval of the plan of care. A plan of care outlines the treatment plan after an evaluation of a patient’s condition and is considered to be established when it is developed, e.g. written or dictated. The signature and professional credentials of the person who established the plan and the date must be supported in the documentation. The plan of care may only be developed by a practitioner or a licensed therapist specific to their specialty, e.g. a physical therapist would complete a plan of care specific for physical therapy services. At a minimum, the plan of care must include the following:

• Diagnosis
• Long term treatment goals
• Type, amount, frequency and duration of therapy services
• Frequency of therapy refers to "the number of times in a week the type of treatment is provided" which can be tapered as necessary. Long term treatment goals should be measurable and related to the patient’s impairments.

Certification requirements are met when the practitioner certifies the minimum required plan of care elements with a legible dated signature on the plan of care or some other document that indicates approval of the plan of care. If the order contains all the required elements of the plan of care and is legibly dated and signed by the practitioner, then no further certification is required.

Timeliness is met when the initial certification is signed within 30 days of the initial treatment under that plan. Recertification of the minimum required plan of care elements must be legibly signed and dated by the practitioner during the duration of the prior plan of care or within 90 days, whichever is less. For example, if frequency and duration on the prior certified plan of care is documented as 2 times a week for 4 weeks, then that certification is valid for 4 weeks and the recertification must be completed by the practitioner within that 4 week time frame to meet the timeliness standard.

Delayed certification/recertification is acceptable without justification for an additional 30 day grace period after they are due. If the plan of care has not been legibly signed and dated within 60 days, the practitioner must also provide a rationale for the delay.

For additional information, reference Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Sections 220(A), 220.1.2 – 220.1.3.

Initial evaluation services involve clinical judgment and decision-making which is not within the scope of practice for therapy assistants. These services can only be provided by qualified clinicians, i.e. a physician, non-physician practitioner (NPP), therapist or speech-language pathologist (SLP). Therapy evaluation codes can only be billed when the medical record supports a completed comprehensive evaluation with sufficient data to support development of a thorough plan of care, including goals and intervention selection. Documentation must support that the evaluative service was medically necessary based on the patient’s current status and medical/functional history. Medicare does not reimburse for services related solely to workplace skills and activities. Treatment codes should not be billed for time spent providing initial evaluative services.

Providers may simultaneously receive multiple physician referrals for multiple medical conditions for one patient. When this occurs, it is expected that one qualified clinician from each appropriate discipline, i.e. physical therapist (PT) and/or occupational therapist (OT), and/or speech language pathologist (SLP) will complete a thorough initial evaluation that encompasses each of the identified medical conditions. Following completion of the initial evaluation, other staff therapists specializing in specific medical conditions may treat the patient as needed. When medical necessity is supported, an initial evaluation is appropriate for:

• A new patient who has not received prior therapy services
• A patient who has returned for additional medically necessary therapy after having been discharged from prior therapy services for the same or different condition. Time spent evaluating this returning patient should not be coded as a re-evaluation. Prior discharge may have been due to one of the following:
• Patient no longer significantly benefited from ongoing therapy services or;
• Patient no longer required therapy services for an extended period of time or;
• Patient experienced a significant change in medical status that necessitated discharge or;
• Patient who is currently receiving therapy services develops a newly diagnosed unrelated condition

For example: A patient is currently receiving therapy services following a total knee arthroplasty (TKA). During the therapy episode of care for the TKA, the patient develops an acute rotator cuff injury from an accident at home. The clinician determines that the rotator cuff injury is not related to the TKA. Therefore, it is reasonable for the clinician to provide and code for a new evaluation of the rotator cuff injury since it is a newly identified diagnosis for an unrelated condition.

For additional information, reference the Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3 (C).

To support medical necessity of therapy services, documentation must support the patient required skilled care. Skilled care would include:

• Services provided which are individualized and rendered for treatment of a medical condition that require the skills and knowledge of a therapist
• Services that meet acceptable standards of medical practice to effectively treat the patient’s condition
• Services that are complex and sophisticated such that they require the judgement and skills of a qualified therapist to be completed safely and effectively
• Rehabilitation services provided should be of a reasonable duration as evidenced by the patient continuing to significantly and objectively benefit from ongoing skilled therapy services

As per the progress report requirements, documentation to support medical necessity for services is minimally required to be documented every 10 treatment days. Without the elements of the progress report documented, medical necessity is difficult to establish. Documentation must also support that the benefits from any prior therapy services for the same condition were sustainable following discharge for a reasonable amount of time.
Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 220.3 outlines requirements for rehabilitative and maintenance therapy as follows:

• Rehabilitative Therapy: "the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time"
• Maintenance Therapy: "treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel"

For additional information, reference: Noridian Coverage Article, "Medical Necessity of Therapy Services A53304 (JE), IOM, Publication 100-02, MBPM, Chapter 15, Section 220-230

Physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP) services that are furnished to a single individual must meet monthly repetitive billing requirements. PT, OT, SLP services need to be billed on a single monthly claim (or at the conclusion of treatment), whichever comes first. For example, when a patient comes to therapy during the month of July and participates in PT, OT and SLP then all the therapy services need to be billed on a single monthly claim for July. A single monthly billing is required for a patient that is:

• Receiving PT, an/or OT, and/or SLP services
• Referred for therapy services by one or more practitioner
• Receiving therapy services for one or more conditions
• Being treated under one or more therapy plans of care
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For additional information, reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 1, Section 50.2.2.

When billing timed codes for outpatient therapy, billing should be based solely on the total timed code treatment minutes provided. If only one timed code service is provided for less than 8 minutes during a single therapy visit, then the service should not be billed. However, if during a single therapy visit 8 minutes of a timed code service is provided in addition to another timed code service, then the total combined minutes for all of the timed code services is used to determine accurate billing of the total timed code unit(s). Additionally, if 2 timed code services are performed, each individually spending 1 unit worth of time, but the total timed code minutes allows 3 units to be billed, then it would be appropriate to bill 3 units based on the total timed code minutes, assigning the additional unit to the service that took the most amount of time.

The expectation remains, however, that a provider’s direct treatment time for each timed code unit will average 15 minutes. If a provider is consistently billing less than 15 minutes for a unit, this may be highlighted for review.
The following are examples to help clarify appropriate billing practices based on total timed code treatment minutes for therapy services:

Example 1 - The treatment encounter note supports:

• 30 minutes initial evaluation, Current Procedural Terminology (CPT®) 97162
• 5 minutes therapeutic exercises, CPT® 97110
• When the visit includes both untimed and timed-based services, the documentation needs to clearly indicate that the total time of the visit was 35 total visit minutes. This documentation supports coding of 1 unit for CPT® 97162 and no coding for CPT® 97110 since the required minimum 8 minute threshold is not met.

Example 2 - The treatment encounter note supports:

• 20 minutes of manual therapy, CPT® 97140
• 20 minutes of therapeutic exercises, CPT® 97110
• The total timed code treatment time is 40 minutes, which allows 3 units to be billed (3 units = 38-52 minutes). Even though each service is performed for only 1 unit of time individually, the total time allows for 3 units. Since both services are performed for the same amount of time, choose 1 service to bill 2 units and the other service is billed for 1 unit.

Example 3 - The treatment encounter note supports:

• 35 minutes of manual therapy, CPT® 97140
• 7 minutes of gait training, CPT® 97116
• Total time-based treatment time is 42 minutes, which allows for 3 units to be billed. The first 30 minutes counted towards CPT® 97140 which supports 2 full units (per the 15 minute relative work value for each unit). The remaining time spent on CPT® 97140 (5 minutes) compared to the time spent on CPT® 97116 (7 minutes) and the service that took more time is the service that should receive the remaining 1 unit. The documentation supports 2 units of CPT® 97140 and 1 unit of CPT® 97116

Example 4 - The treatment encounter note supports:

• 25 minutes of therapeutic exercises, CPT® 97110
• 24 minutes of therapeutic activities, CPT® 97530
• Total timed-based treatment time is 49 minutes, which allows for 3 units to be billed. Therefore, even though each individual service is performed for 2 units worth of time, the total time allows for only 3 units. The documentation supports 2 units of CPT® 97110 and 1 unit of CPT® 97530, billing more timed units to the service that took the most time.

Example 5 - The treatment encounter note supports:

• 20 minutes of manual therapy, CPT® 97140
• 10 minutes of therapeutic exercises, CPT® 97110
• 10 minutes of gait training, CPT® 97116
• 8 minutes of ultrasound, CPT® 97035
• Total time-based treatment time is 48 minutes, which allows for 3 units to be billed. Therefore, even though each individual service is performed for 1 unit worth of time, the total time allows for only 3 units. This documentation supports 1 unit each of CPT® 97140, 97110, 97116. The ultrasound is not able to be billed, as the total units that can be billed are constrained by the total timed code treatment minutes. (In order to bill 4 units, there must be 53-67 total time-based treatment minutes).

Example 6 - The treatment encounter note supports:

• 10 minutes of vasopneumatic device, CPT® 97016
• 21 minutes of therapeutic exercises, CPT® 97110
• 9 minutes of manual therapy, CPT® 97140
• The total treatment time is 40 minutes and the total time-based treatment is 30 minutes. This documentation supports 1 unit of CPT® 97016, 1 unit of CPT® 97110 and 1 unit of CPT® 97140.

For additional information, reference the Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual (MCPM), Chapter 5, Section 20.2.