Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services

Notification Issue Date:

This AmeriHealth New Jersey Medicare Advantage policy will become effective 01/01/2024.

Title:

Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services

Policy #:

MA00.050a

Policy

The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.

This policy applies to outpatient facility providers billing on a CMS-1450 (UB-04) claim form, or the equivalent form 837i, for members enrolled in all Company products.

Multiple procedure payment reduction (MPPR) guidelines for physical, occupational, and speech therapy services designated as Always Therapy are used to determine the provider's reimbursement for eligible therapy services.

Refer to Attachment A of this policy for services that are designated as Always Therapy services.

MPPR guidelines apply when multiple physical, occupational, and speech therapy services designated as Always Therapy are reported by the same provider, for the same individual, on the same date of service.

The procedure code with the highest total allowance is eligible for reimbursement at 100 percent of the provider's applicable contracted rate.
Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

These MPPR guidelines only apply to services that are designated as Always Therapy and would not impact reimbursement consideration for services that are not designated as Always Therapy.

NONCOVERED AND NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT

Multiple procedure payment reduction guidelines for physical, occupational, and speech therapy services are not applied to services that are non-covered or not eligible for separate reimbursement consideration.

REQUIRED DOCUMENTATION

These Always Therapy codes require a therapy modifier to indicate that the services are furnished under a physical, occupational, or speech therapy plan of care.

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, the following: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

Guidelines

This claim payment rationale applies only to the procedure codes in Attachment A of this policy. Claims reported with services designated as Always Therapy are processed in accordance with this policy. When another policy on physical, occupational, or speech therapies exists, the criteria and coverage information listed in the medical policy must also be met.

Multiple procedure payment reduction (MPPR) guidelines for services that are designated as Always Therapy are based on the date of service regardless of the claim submission date or date received.

Description

In accordance with The Centers for Medicare & Medicaid Services (CMS), the Company has established claims processing guidelines for multiple physical, occupational, and speech therapy services that are designated as Always Therapy.

CMS designates certain procedure codes as Always Therapy. Such procedure codes are assigned a therapy disposition code of "5" by CMS. These codes always represent therapy services when rendered by therapists or by practitioners who are not therapists in situations where the service provided is integral to an outpatient rehabilitation therapy plan of care. For these situations, these codes must always have a therapy modifier.

References

Centers for Medicare & Medicaid Services (CMS). MLN Matters Number MM8206. Effective April 1, 2013. [CMS Website]. Available at: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnmattersarticles/downloads/MM8206.pdf. Accessed March 15, 2019.

Centers for Medicare & Medicaid Services (CMS). Annual Therapy Update. 2019 Therapy Code List and Dispositions. [CMS Website]. Available at:
https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html. Accessed March 15, 2019.

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 5: Part B Outpatient Rehabilitation and CORF/OPT Services. Revised 03/09/18. [CMS Website]. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf. Accessed March 15, 2019.

Novitas Solutions. Multiple Procedure Payment Reduction. [Novitas Solutions Web site]. Last modified: 03/14/2019. Available at: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?centerWidth=100%&contentId=00147106&leftWidth=0%&rightWidth=0%&showFooter=false&showHeader=false&_adf.ctrl-state=tl57mjwsj_4&_afrLoop=309444304661771#!. Accessed March 15, 2019.

Coding

CPT Procedure Code Number(s)

Refer to Attachment A of this policy for services that are designated as Always Therapy services.

ICD - 10 Procedure Code Number(s)

N/A

ICD - 10 Diagnosis Code Number(s)

N/A

HCPCS Level II Code Number(s)

Refer to Attachment A of this policy for services that are designated as Always Therapy services.

Revenue Code Number(s)

N/A

MPMiscCodesNarrativesPub
Modifiers

CO Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

CQ Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant

GN Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care

GO Service delivered personally by an occupational therapist or under an outpatient occupational therapy plan of care

GP Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From MA00.050a:

01/02/2024

This policy has been identified and updated for the CPT/HCPCS code update effective 01/02/2024

Procedure codes 97550 and 97552 have been added to this policy.

Revisions From MA00.050:

01/01/2024	Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.
09/01/2019	This new policy becomes effective 09/01/2019 and applies to outpatient facility providers. Multiple procedure payment reduction guidelines for multiple therapies apply to physical, occupational, and speech therapy services designated as Always Therapy that are reported by the same provider, for the same individual, on the same date of service. The procedure code with the highest total allowance is eligible for reimbursement at 100 percent of the provider's applicable contracted rate. Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

01/01/2024

Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.

09/01/2019

This new policy becomes effective 09/01/2019 and applies to outpatient facility providers. Multiple procedure payment reduction guidelines for multiple therapies apply to physical, occupational, and speech therapy services designated as Always Therapy that are reported by the same provider, for the same individual, on the same date of service.

The procedure code with the highest total allowance is eligible for reimbursement at 100 percent of the provider's applicable contracted rate.
Each subsequent procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

Version Effective Date:

1/2/2024

Version Issued Date:

1/26/2024

Version Reissued Date: