List of Rehab/Therapy and Chiropractic Manipulation CPTs and descriptions
|G0283||EMS/IFC, 1 or more areas|
|98940||Spinal Manipulation 1-2 regions|
|98941||Spinal Manipulation 3-4 regions|
|98942||Spinal Manipulation 5+ regions|
|98943||Extraspinal, 1 or more regions|
Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services – General
Section §1834(k)(5) to the Social Security Act (the Act), requires that all claims for outpatient rehabilitation services and comprehensive outpatient rehabilitation facility (CORF) services, be reported using a uniform coding system. The CMS chose HCPCS (Healthcare Common Procedure Coding System) as the coding system to be used for the reporting of these services. This coding requirement is effective for all claims for outpatient rehabilitation services and CORF services submitted on or after April 1, 1998.
The Act also requires payment under a prospective payment system for outpatient rehabilitation services including CORF services. Effective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for outpatient therapy services furnished by:
• Comprehensive outpatient rehabilitation facilities (CORFs);
• Outpatient physical therapy providers (OPTs), also known as rehabilitation agencies;
• Skilled nursing facilities (SNFs) (to residents not in a covered Part A stay and to nonresidents who receive outpatient rehabilitation services from the SNF); and
Similarly, under the HH prospective payment system, HHAs are responsible to provide, either directly or under arrangements, all outpatient rehabilitation therapy services to beneficiaries receiving services under a home health POC. No other provider or supplier will be paid for these services during the time the beneficiary is in a covered Part A stay. For information regarding HH consolidated billing see chapter10, section 20 of this manual.
The MPFS is used as a method of payment for outpatient rehabilitation services furnished under arrangement with any of these providers.
Services that are paid subject to the MPFS are adjusted based on the applicable payment locality. Rehabilitation agencies and CORFs with service locations in different payment localities shall follow the instructions for multiple service locations in chapter 1, section 170.1.1.
The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs) or hospitals in Maryland. CAHs are to be paid on a reasonable cost basis. Maryland hospitals are paid under the Maryland All-Payer Model.
Contractors process outpatient rehabilitation claims from hospitals, including CAHs, SNFs, HHAs, CORFs, outpatient rehabilitation agencies, and outpatient physical therapy providers for which they have received a tie in notice from the Regional Office (RO).
Contractors pay the codes in §20 under the MPFS on professional claims regardless of whether they may be considered rehabilitation services. However, contractors must use this list for institutional claims to determine whether to pay under outpatient rehabilitation rules or whether payment rules for other types of service may apply, e.g., OPPS for hospitals, reasonable costs for CAHs.
Note that because a service is considered an outpatient rehabilitation service does not automatically imply payment for that service. Additional criteria, including coverage, plan of care and physician certification must also be met. These criteria are described in Pub. 100-02, Medicare Benefit Policy Manual, chapters 1 and 15.
Payment for rehabilitation services provided to Part A inpatients of hospitals or SNFs is included in the respective PPS rate. Also, for SNFs (but not hospitals), if the beneficiary has Part B, but not Part A coverage (e.g., Part A benefits are exhausted), the SNF must bill for any rehabilitation service.
Payment for rehabilitation therapy services provided by home health agencies under a home health plan of care is included in the home health PPS rate. HHAs may submit bill type 34X and be paid under the MPFS if there are no home health services billed under a home health plan of care at the same time, and there is a valid rehabilitation POC (e.g., the patient is not homebound).
The MPFS is the basis of payment for outpatient rehabilitation services furnished by TPPs, physicians, and certain non physician practitioners or for diagnostic tests provided incident to the services of such physicians or non physician practitioners. (See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, for a definition of “incident to, therapist, therapy and related instructions.”) Such services are billed to the contractor on the professional claim format. Assignment is mandatory.
NOTE: The list of codes in §20 contains commonly utilized codes for outpatient rehabilitation services. Contractors may consider other codes on institutional claims for payment under the MPFS as outpatient rehabilitation services to the extent that such codes are determined to be medically reasonable and necessary and could be performed within the scope of practice of the therapist providing the service.
Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33) of 1997, which added §1834(k)(5) to the Act, required payment under a prospective payment system (PPS) for outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). Outpatient rehabilitation services include the following services:
• Physical therapy
• Speech-language pathology; and
• Occupational therapy.
Section 4541(c) of the BBA required application of financial limitations to all outpatient rehabilitation services (except those furnished by or under arrangements with a hospital). In 1999, an annual per beneficiary limit of $1,500 was applied.
Since the limitations apply to outpatient services, they do not apply to skilled nursing facility (SNF) residents in a covered Part A stay, including patients occupying swing beds. Rehabilitation services are included within the global Part A per diem payment that the SNF receives under the prospective payment system (PPS) for the covered stay. Also, limitations do not apply to any therapy services covered under prospective payment systems for home health or inpatient hospitals, including critical access hospitals.