Physician Orders and Certification Guidelines

The CORF/OPT services must be furnished under a written plan of treatment that is established and signed by the physician or non-physician practitioner (NPP) who has recently evaluated the patient. It is expected, but not essential, that the physician will establish the plan in consultation with the physical therapist, occupational therapists, or speech-language pathologists who provide the actual therapy. The physician wholly establishes any respiratory therapy plan of care.

For OPT services the physician must certify the initial plan of treatment or a significantly modified plan of treatment within 30 days. If the patient continues under the same treatment plan, the recertification is considered timely when they are dated during the duration of the initial plan of treatment or within 90 calendar days from the initial therapy treatment under that plan, whichever is less. The physician should determine that the plan of treatment is followed and that the patient is making progress in attaining the established skilled rehabilitation goals. Note: The plan of treatment must be established, certified, and signed by a physician prior to initial treatment in a CORF setting.

CORF/OPT services cannot be provided to patients residing in a Medicare-certified skilled nursing bed; however, SNFs may contract with CORF/OPTs to provide therapy services. The SNF is responsible for the oversight, delivery, and billing of the contracted services.

CORF/OPT services are subject to annual per beneficiary limitations.

Providers should issue an Advance Beneficiary Notice of Noncoverage (ABN) when the CORF/OPT continues to give care beyond reasonable and medically necessary Medicare coverage.

CORF/OPT Billing

Skilled Rehab Services Provided in a CORF and an OPT is Paid Under Medicare Physician Fee Schedule (MPFS)

CORF

  • Type of bill (TOB) 75X
  • Line item date of service (DOS) for each revenue code (RC): RC 41X, 42X, 43X, 44X require units, occurrence codes, therapy modifiers, functional therapy G-codes and severity modifiers
  • Accurate HCPCS required, subject to National Correct Coding Initiative (NCCI) Edits
  • Supplies used in splints and casts for reduction of fractures and dislocations may be billed: RC 27X, HCPCS Q4001-Q4051

ORF/OPT

  • TOB 74X
  • Line item DOS for each RC: RC 42X, 43X, 44X require units, occurrence codes, therapy modifiers, functional therapy G-codes and severity modifiers
  • Accurate HCPCS required, subject to NCCI edits
  • Supplies used in splints and casts for reduction of fractures and dislocations may be billed: RC 27X, HCPCS Q4001-Q4051

Billing Requirements

Therapy Revenue Code Modifier Occurrence Codes
Physical Therapy 42X GP - Service delivered personally by PT or under PT POC 11 - Onset of symptoms/illness
29 - Date PT POC established or last reviewed
35 - Date PT treatment started
Occupational Therapy 43X GO - Service delivered personally by OT or under OT POC 11 - Onset of symptoms/illness
17 - Date OT POC established or last reviewed
44 - Date OT treatment started
Speech Language Pathology 44X GN - Service delivered personally by SLP or under SLP POC 11 - Onset of symptoms/illness
30 - Date SLP POC established or last reviewed
45 - Date SLP treatment

 

Other Allowable Services and Revenue Codes

  • Social work and Psychological Services: RC 560, 569, 900, 911, 914, and 919
  • Respiratory Therapy Services: RC 410, 412, and 419 only
  • Nursing Services: RC 550, 559 only
  • Drugs, Biologicals and Supplies: RC 636 and 771

Resources

 

Last Updated Fri, 14 Feb 2020 11:58:10 +0000