Notification



Notification Issue Date:



Claim Payment Policy


Title:Outpatient Short-Term Rehabilitation Services Included in Capitation

Policy #:00.03.03g

This policy is applicable to the Company’s commercial products only. Policies that are applicable to the Company’s Medicare Advantage products are accessible via a separate Medicare Advantage policy database.

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, 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 decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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


Coverage is subject to the terms, conditions, and limitations of the member's contract.

Outpatient short-term rehabilitation services included in capitation are reimbursed on a monthly basis and are, therefore, not eligible for fee-for-service reimbursement consideration. The services listed in Attachment A are reimbursed in capitation to outpatient short-term rehabilitation providers designated by the primary care physicians (PCPs) of Health Maintenance Organization (HMO) members who utilize their referred benefit and who are enrolled in one of the following:

  • 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, Montgomery, and Philadelphia.

PCPs in NJ and PA counties not listed above are not required to choose a designated outpatient short-term rehabilitation provider.

Individual member benefits must be verified, as some groups exclude or limit coverage for short-term rehabilitation services. Services that are a benefit contract exclusion are noncovered and, therefore, not included in capitation.
Guidelines

Certain procedures that are included in capitation may be eligible for fee-for-service reimbursement to a provider when specific requirements are met. For information on policies related to this topic, refer to the Cross References section in this policy.

Therapy services (ie, physical therapy, occupational therapy, speech therapy) provided as part of a Day Rehabilitation Program are a separate benefit category and are not subject to the requirements stated in this policy.

As mandated by the state of New Jersey, members enrolled in NJ Health Maintenance Organization (HMO) or HMO Point-of-Service (POS) products may elect to use their in-network benefits to obtain outpatient short-term rehabilitation services from a participating provider other than the primary care physician's (PCP) designated outpatient short-term rehabilitation provider. However, referral requirements apply.

Supporting medical necessity documentation must be maintained in medical records and made available to the Company upon request.
Description

Outpatient short-term rehabilitation therapy is the medically prescribed treatment of physical disabilities or impairments that result from disease, injury, congenital anomaly, and/or prior therapeutic intervention for an individual's medical condition. These services are performed on an outpatient basis over a short period of time. Examples of outpatient short-term rehabilitation therapy include some physical therapy (PT) and occupational therapy (OT) services.

Capitation is the reimbursement that a participating facility or professional provider receives in advance of services for a Health Maintenance Organization (HMO) member or for an HMO Point-of-Service (POS) member who utilizes his/her referred benefit. The designated outpatient rehabilitation provider is the source for all outpatient short-term rehabilitation therapy services. Reimbursement, which is a set dollar amount, is based on the provider's panel of members each month.
  • As used in this policy, HMO also refers to HMO POS when the individual utilizes his/her referred benefit.

References


Company benefit contracts.

New Jersey Department of Banking and Insurance. New Jersey Administrative Code. Title 11: Insurance. Chapter 24: Health Maintenance Organizations. Subchapter 9: Member rights and responsibilities: Disclosures to consumers. 11:24-9.1: Policies and procedures. [The State of New Jersey Web site]. Original: 12/31/02. (Recodified: 10/06/06). Available at: http://www.state.nj.us/dobi/division_insurance/managedcare/omc/njac11c24.pdf. Accessed March 20, 2008.

Stanos SP, Tyburski MD, Harden RN. Management of chronic pain: Multidisciplinary and interdisciplinary approaches. In: Braddom RL, Buschbacher RM, Chan L, et al.,eds. Physical Medicine and Rehabilitation. 3rd ed. Philadelphia, PA: WB Saunders Co.; 2007:966-968.




Coding

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.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

Refer to Attachment A for a list of procedure codes included in capitation for Delaware (DE), New Jersey (NJ), and Pennsylvania (PA) outpatient short-term rehabilitation providers.


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

Refer to Attachment A for a list of procedure codes included in capitation for DE, NJ, and PA outpatient short-term rehabilitation providers.


Revenue Code Number(s)

Refer to Attachment A for a list of procedure codes included in capitation for DE, NJ, and PA outpatient short-term rehabilitation providers.

Coding and Billing Requirements


Cross References

Attachment A: Outpatient Short-Term Rehabilitation Services Included in Capitation


Policy History

REVISIONS FROM 00.03.03g:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018:

The following CPT codes have been added to this policy:
97127, 97663, G0515

The following CPT code has been deleted from this policy:
97762

The following CPT code narratives have been revised in this policy:
97760, 97761

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04/12/2018: Code G0105 was incorrectly listed. The typographic error was corrected to G0515.
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.