Comprehensive Outpatient Rehabilitation Facility Billing Guide

Requirement Description
Unique Identifying Provider Number Ranges
  • 3200-3299
  • 4500-4599
  • 4800-4899

Bill Type

CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 80.3.2.2

  • 751 - Admit thru discharge
  • 757 - Adjustment
  • 758 - Cancel
  • 750 - No payment

Billable Visit

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 12, Section 10

CORF services are covered only if they relate directly to the rehabilitation for the treatment of injured, disabled, or sick patients.
The services must be skilled, reasonable and necessary, treating an illness or injury to improve function of a malformed body member.

CORF Qualified Staff and Practitioners

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 12 Section 40

  • Physician
    • Diagnostic and therapeutic services bill on the CMS-1500
  • Physical Therapist (PT), Occupational Therapist (OT), Speech-Language Pathologist
    • Appropriately supervised and qualified Physical Therapist Assistant (PTA) or Occupational Therapist Assistant (COTA).
  • Respiratory Therapist
  • Social Worker
    •  Bachelor of Science Degree
  • Psychologist
    • Masters-level Degree
  • Registered Nurse

Revenue Codes

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 100

Reportable/Billable:
  • 027X
  • 0410, 0412, 0419
  • 042X, 043X, 044X
    • HCPCS required
  • 0550, 0559
  • 0569
  • 0636
  • 0771
  • 0911
  • 0942
PT, OT, SLP
CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5
Therapy annual financial limitations apply. Line item billing with HCPCS, therapy modifiers and therapy functional reporting codes.

Social Work and Psychological Services

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 100.4

  • Directly relating to patient's rehabilitation goals provided by CORF-qualified Social Worker or Psychologist.
  • Bill HCPCS code G0409
  • Revenue code 0560, 0569, 0910, 0911, 0914 and 0919

Respiratory Therapy Services

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 100.12

  • Provided by respiratory therapist to support or adjunct to rehabilitation plan of treatment.
  • HCPCS 94664, 94667, 94668
  • Revenue code 0410, 0412, 0419
  • Separate payment not made for diagnostic tests or services related to physiologic monitoring.
    • Bundled into other respiratory services; HCPCS codes G0237, G0238 and G0239.

Nursing Services

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 100.3

  • Skilled nursing services provided by Registered Nurse (RN) to support or adjunct to rehabilitation plan of treatment.
  • HCPCS code G0128
  • Revenue Code 0550 and 0559

Preventive Services

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 12, Section 40.11

  • Vaccines and administrations covered when provided under a physician order for a CORF patient.
    • Influenza Virus Vaccine - G0008
    • Pneumococcal Vaccine - G0009
    • Hepatitis B Vaccine - G0010
  • See Preventive Services

Drugs and Biologicals

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 12, Section 40.9

  • Generally, drugs and biologicals do not apply in the CORF; not billable.

Supplies

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 12, Section 40.6

  • Other supplies are included in Medicare Physician Fee Schedule (MPFS) and not billed separately.
  • Only bill supplies for splint and cast; used for the reduction of fractures and dislocations.
    • Level I HCPCS range 29000-29085 and
    • Level II HCPCS Q-codes range Q4001-Q4049.
  • When these services are provided by therapists or as an integral part of a therapy plan of care, the code must be accompanied with the appropriate therapy modifier.

Reimbursement

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 170.1.1

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 10

  • Paid using the MPFS for outpatient rehabilitation services  and payment is adjusted based on locality.
  • For one service location the fee amount is determined using ZIP code of master address in provider file.
  • Multiple sites must report nine-digit ZIP code when services are provided in a different locality than the parent provider for proper payment.

Payment Type

CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 12, Section 30.1

Payment is calculated at 80 percent of the allowed charge after deductible is met. Unmet deductible is subtracted from the allowed charge.

Frequency of Billing

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 50.2.2

All services provided to a single individual should be submitted monthly (or at the conclusion of treatement) for repetitive services. See IOM for CMS list of revenue codes defined as repetitive services.
  • Submit a monthly bill for all line item dates of service for the entire month's recurring services with all services related to the recurring service.

Statutorily Excluded Services

CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5, Section 100.6

  • If a service is excluded by statute, the CORF may submit a claim for them to Medicare to obtain a denial prior to billing another insurance carrier.
  • Use condition code 21 and all charges non-covered.
Beneficiary Coinsurance See Annual Benefits
Beneficiary Deductible See Annual Benefits

 

Last Updated Sat, 18 Apr 2020 13:01:36 +0000