Notification



Notification Issue Date:



Policy Attachment


Attachment to Policy # 00.03.03g


Attachment:A

Policy #:00.03.03g

Description:

Title:Outpatient Short-Term Rehabilitation Services Included in Capitation


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.



Note: On 04/12/2018 a typographic error was corrected. Code G0105 was corrected to G0515.

OUTPATIENT SHORT-TERM REHABILITATION SERVICE PROCEDURE CODES INCLUDED IN CAPITATION FOR DELAWARE, NEW JERSEY (NJ), AND PENNSYLVANIA (PA) HEALTH MAINTENANCE ORGANIZATION (HMO) AND HMO POINT-OF-SERVICE (POS) MEMBERS

The procedure codes (HCPCS, CPT, and Revenue) listed in this attachment are included in capitation to outpatient short-term rehabilitation providers designated by the primary care physicians (PCPs) of members who are enrolled in the following regional HMO and HMO POS products:
  • Delaware-based Commercial HMO products
  • NJ-based Commercial and Medicare Advantage HMO products with members who select a PCP in any of the following NJ counties: Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Ocean, and Salem
  • PA-based Commercial and Medicare Advantage HMO products with members who select a PCP in any of the following PA counties: Bucks, Chester, Delaware, Chester, Montgomery, and Philadelphia

Individual member benefits must be verified, as some groups exclude or limit coverage for outpatient short-term rehabilitation services.

TABLE I: CPT AND HCPCS LEVEL II PROCEDURE CODES
Inclusion of a code in this policy table does not guarantee coverage. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

Note: on 02/02/2017 the following codes were removed from Attachment A : 97169, 97170, 97171, 97172.
PROCEDURE CODE
97010
97012
97014
97016
97018
97022
97024
97026
97028
97032
97033
97034
97035
97036
97039
97110
97112
97113
97116
97124
97127
97139
97140
97150
97161
97162
97163
97164
97165
97166
97167
97168
97530
97535
97537
97542
97545
97546
97610
97750
97755
97760
97761
97763
97799
G0515
G0283


TABLE II: REVENUE CODES

Inclusion of a code in this policy table does not guarantee coverage. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply.

REVENUE CODE
NARRATIVE
420
General classification for physical therapy
421
Physical therapy visit charge
422
Physical therapy hourly charge
423
Physical therapy group rate
424
Physical therapy evaluation and/or reevaluation
429
Other physical therapy services
430
General classification for occupational therapy
431
Occupational therapy visit charge
432
Occupational therapy hourly charge
433
Occupational therapy group rate
434
Occupational therapy evaluation or reevaluation
439
Other occupational therapy services



Version Effective Date: 01/01/2018
Version Issued Date: 01/05/2018
Version Reissued Date: N/A

Connect with Us        


2017 Independence Blue Cross.
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.