Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.03.06e


Attachment:C

Policy #:00.03.06e

Description:PELVIC FLOOR THERAPY SERVICES

Title:Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



PELVIC FLOOR THERAPY SERVICES ELIGIBLE FOR REIMBURSEMENT ABOVE CAPITATION


NOTES:
  • The Effective Date indicates the date the code became eligible for reimbursement consideration above the monthly capitation fee.
  • The Delete Date indicates either the date the code becomes invalid and/or the date the code is no longer eligible for reimbursement consideration above the monthly capitation fee.
  • Claims will be considered for reimbursement above the monthly capitation fee, when the professional provider reports a listed procedure or revenue code in conjunction with a listed diagnosis code.
Procedure Code
Effective Date
Delete Date
97001
04-01-11
12-31-16
97140
04-01-11
97161
01-01-17
97162
01-01-17
97163
01-01-17
97164
01-01-17
Revenue Code
Effective Date
Delete Date
0420
04-01-11
0421
04-01-11
0422
04-01-11
0423
04-01-11
0429
04-01-11
0430
04-01-11
0431
04-01-11
0432
04-01-11
0433
04-01-11
0439
04-01-11
Diagnosis Code
Effective Date
Delete Date
F52.5
08-22-16
F52.6
08-22-16
N30.10
08-22-16
N30.11
08-22-16
N31.8
08-22-16
N32.81
08-22-16
N39.3
10-01-15
N39.41
10-01-15
N39.42
10-01-15
N39.43
10-01-15
N39.44
10-01-15
N39.45
10-01-15
N39.46
10-01-15
N39.490
10-01-15
N39.491
10-01-16
N39.492
10-01-16
N39.498
10-01-15
N94.1
08-22-16
N94.2
08-22-16
N94.810
08-22-16
N94.818
08-22-16
N94.819
08-22-16
R10.2
08-22-16
R15.9
08-22-16
R32
10-01-15
Version Effective Date: 01/01/2018
Version Issued Date: 01/05/2018
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.