CMS Issues Medicare Benefit Policy Manual Clarification on Outpatient Therapy Services
New Therapy Services Manual Revisions to the Medicare Benefit Policy Manual (Pub 100-02), Chapter 15, Sections 220 and 230, Issued May 6, 2005
The Centers for Medicare and Medicaid Services (CMS) recently released a long-awaited clarification to Medicare therapy policy that should facilitate provision of outpatient occupational therapy treatment to Medicare patients.
This transmittal (i.e. Change Request) defines terms used by CMS in Medicare policy, provides references to additional therapy regulatory and manual requirements, clarifies many existing coverage requirements, and incorporates new policy from the Final Medicare Fee Schedule Rule of November 15, 2004.
Occupational therapists should review the entire Change Request, the provider education article and slide show presentation.
These changes were to take effect June 6, 2005, but were delayed by a lawsuit until July 25.
This article summarizes some of the key provisions in the Medicare Benefit Policy Manual transmittal (Change Request 3648, chapter 15, sections 220 and 230). Some therapy requirements differ for services provided and billed by comprehensive outpatient rehabilitation facilities (CORF).
Definitions of Terms
Assessment is included in services or procedures and is not separately payable (as distinguished from Current Procedural Terminology (CPT) codes that specify an assessment [e.g., 97755, Assistive Technology Assessment] which may be payable). Assessments require professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). For example, assessments can determine changes in the patient's status since the professional's last visit and whether the planned procedure or service should be modified. Based on assessment data, the professional may make judgments about progress toward goals and/or determine that a more complete evaluation is needed.
Certification is the physician's/nonphysician practitioner's (NPP) approval of the plan of care.
Evaluation is a separately payable comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated, based on objective measurements and subjective evaluations of patient performance and functional abilities. For example, evaluation is warranted for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions. The time spent in evaluation does not also count as treatment time.
Reevaluation is separately payable and is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient's condition or functional status. Some regulations and state practice acts require reevaluation at specific intervals. Reevaluation also may be appropriate at a planned discharge. A reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services. Reevaluation requires the same professional skills as evaluation. CPT does not define a reevaluation code for speech-language pathology; use the evaluation code.
Interval of treatment consists of 1 month or 30 calendar days.
Nonphysician Practitioners (NPP) means physician assistants, clinical nurse specialists, and nurse practitioners who may, if state and local laws permit it, and when appropriate rules are followed, provide, certify or supervise therapy services. (Note: A NPP may not order or certify therapy in a CORF.)
Physician with respect to outpatient rehabilitation therapy services means a doctor of medicine, osteopathy (including an osteopathic practitioner), podiatric medicine, or optometry (for low vision rehabilitation only). Chiropractors and doctors of dental surgery or dental medicine are not considered physicians for therapy services and may neither refer patients for rehabilitation therapy services nor establish therapy plans of care.
Providers of services are defined in §1861(u) of the Act, 42CFR400.202 and 42CFR485 Subpart H as participating hospitals, critical access hospitals (CAH), skilled nursing facilities (SNF), comprehensive outpatient rehabilitation facilities (CORF), home health agencies (HHA), hospices, participating clinics, rehabilitation agencies or outpatient rehabilitation facilities (ORF). Providers are also defined as public health agencies with agreements only to furnish outpatient therapy services, or community mental health centers with agreements only to furnish partial hospitalization services.
Qualified Professional means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician's assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies. Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law. Assistants may not supervise others.
Qualified Personnel means staff (auxiliary personnel) who may or may not be licensed as therapists or therapist assistants but who meet all of the requirements for therapists with the exception of licensure. Qualified personnel have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP.
Signature means a legible identifier of any type (e.g., handwritten, electronic, or signature stamp). Policies in Pub. 100-08, Medicare Program Integrity Manual, chapter 3, §220.127.116.11(B) concerning signatures apply.
Supervision Levels for outpatient rehabilitation therapy services are the same as those for diagnostic tests defined in 42CFR410.32. Depending on the setting, the levels include personal supervision (in the room), direct supervision (in the office suite), and general supervision (physician/NPP is available but not necessarily on the premises).
Suppliers of therapy services include individual practitioners such as physicians, NPPs, physical therapists, and occupational therapists who have Medicare provider numbers. Regulatory references on physical therapists in private practice and occupational therapists in private practice (OTPPs) can be found at 42CFR410.60(C)(1), 485.701-729, and 486.150-163.
Therapist refers only to qualified physical therapists, occupational therapists, and speech-language pathologists.
Plan of Care (POC) and Related Requirements
- POC must be established in writing by a physician/nonphysician practitioner (NPP), or therapist.
- A patient must be referred by and under the care of a physician/NPP.
- A physician/NPP must certify the POC.
- Treatment begins after the POC is established. A therapy evaluation and treatment may be provided and billed on the same day.
- A therapist may not significantly alter a POC (e.g., change long-term goals) without the physician's/NPP's written approval. A therapist may make minor alterations (e.g. modifications of short-term goals, changes to procedures used, decreases in frequency and duration) independently.
Certification and Recertification
- The physician's/NPP's certification of the plan for the first 30 days of treatment (with or without an order) satisfies all of the certification requirements for the first interval of 30 calendar days or 1 month of treatment.
- Timely certification of the first interval of treatment is met when physician/NPP certification of the plan for the first interval of treatment is documented, by signature or verbal order, and dated before the end of the interval. If the order to certify is verbal, to be timely it must be followed within 14 days by a signature. A dated notation of the order to certify the plan should be made in the patient's medical record.
- To complete the certification requirements, the plan must be reviewed, dated, and signed every 30 days by the physician/NPP responsible for the patient's care at that time, unless delayed certification requirements are met. The review and recertification need not be done by same physician/NPP who originally ordered and certified the therapy.
- Delayed certification and recertification may be acceptable after 30 days, when a physician/NPP makes a certification and the provider submits documentation supporting the reason for the delay.
- Technical denials of claims resulting from failure to obtain timely certifications may be overturned if the certification is produced at a later date. Patients have no liability for payment if services rendered by a provider (see definitions of terms) are denied. Patients receiving services in physicians' or occupational therapy private practitioners' offices may be billed if the supplier receives a technical denial due to a lack of certification.
Reasonable and Necessary
- Occupational therapy services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified occupational therapist, or under the supervision of a qualified occupational therapist.
- Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed or supervised by a qualified professional.
- Services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient's condition. Acceptable practices for therapy services are found in:
- Medicare manuals (such as Publications 100-02, 100-03 and 100-04),
- contractors' local coverage determinations (LCDs); LCDs and national coverage determinations are available on the Medicare Coverage Database: ( http://www.cms.hhs.gov/mcd), and
- guidelines and literature of the profession of occupational therapy.
Services Furnished by Occupational Therapists in Private Practice (OTPP)
This section reiterates the definition of OTPP and summarizes requirements previously published in the Federal Register and other CMS manuals concerning acceptable place of service codes, rules for supervision of staff, and accepting assignment of Medicare payment. OTPPs should read these requirements in their entirety.
Occupational Therapy Services Provided Incident to Physician Services
- Therapists working in physician offices or group practices may provide services either through their own private practice numbers or as employees of the physician practice through the physician's provider number.
- In order to provide and bill for therapy services, auxiliary personnel working incident to physicians must meet the same requirements as therapists, with the exception of having a license, unless required by state law. Therefore, physicians can no longer bill services provided by athletic trainers, massage therapists, recreation therapists, kinesiotherapists, low vision specialists, or any profession other than occupational therapy, physical therapy, or speech-language pathology, as therapy.
- Services of an OTA may not be billed incident to a physician; however, if an occupational therapist (OT) and OTA are both employed in a physician's office, the OT is enrolled in Medicare with an OTPP provider number, and the services of the OTA are directly supervised by the OT, the OTA's services may be billed by the physician group as OT services using the provider identification number of the enrolled OT.
Therapy Services Furnished Under Arrangements
This section pertains to providers, such as hospitals and skilled nursing facilities, that contract with occupational therapists to provide therapy services to its patients. CMS states that "it is not intended that the provider merely serve as a billing mechanism for the other party. For such services to be covered, the provider must assume professional responsibility for the services." This includes
- maintaining a complete and timely clinical record on the patient that includes diagnosis, medical history, orders, and progress notes relating to all services received;
- maintaining communication with the attending physician/NPP regarding the progress of the patient and to assure that the required plan of treatment is periodically reviewed by the physician/NPP;
- securing from the physician/NPP the required certifications and recertifications; and
- ensuring that the medical necessity of such service is reviewed on a sample basis by the agency's staff or an outside review group.
In this transmittal, CMS also addresses the issues of rehabilitation for chronic or terminal conditions, maintenance programs, and coverage of occupational therapy, including for patients with "specific diagnosed psychiatric illness."
The above highlights do not contain the entire text of the May 6, 2005 transmittal, nor Medicare therapy policy (e.g., related to coding) found in related manual sections. Occupational therapists should familiarize themselves with the general format and content of all Medicare therapy resources available on the CMS Web site.