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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-Serv
00.03.06g

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Policy

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

This policy applies to members enrolled in Health Maintenance Organization (HMO) products, including those enrolled in Health Maintenance Organization Point-of-Service (HMO-POS) products, who utilize their referred benefit.

In geographic regions with a capitated physical and occupational therapy (PT/OT) program, members enrolled in HMO or HMO-POS products are required to obtain PT/OT services at their Primary Care Physician's (PCP's) designated PT/OT capitated site. The designated PT/OT capitated site receives reimbursement in advance for services rendered to HMO and HMO-POS members.

Medically necessary PT/OT services are eligible for above capitation reimbursement by the Company to the designated PT/OT capitated site when both of the following criteria are met:
  • The PT/OT service is provided for any of the following:
    • Hand Therapy
    • Lymphedema Therapy
    • Pelvic Floor Therapy for the Treatment of Urinary Incontinence
    • Vestibular Rehabilitation
  • The Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS) or revenue code that represents the applicable therapy service and the diagnosis code that is representative of the patient's condition appear in one of the following Attachments A-D:
    • Attachment A: Hand Therapy Services
    • Attachment B: Lymphedema Therapy Services
    • Attachment C: Pelvic Floor Therapy Services
    • Attachment D: Vestibular Rehabilitation Services
Individual member benefits must be verified, as some groups exclude or limit coverage for PT/OT services.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: 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

Physical and occupational therapy services (PT/OT) eligible above capitation reimbursement apply to all regions that include a capitated PT/OT program.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, PT/OT is, generally, included in capitation for all HMO and HMO-POS products of the Company, when a member is utilizing his/her referred level of benefits.

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

MANDATES
This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

Description

Capitation is the reimbursement a participating facility or professional provider receives in advance of services for a Health Maintenance Organization (HMO) member or for an Health Maintenance Organization Point-of-Service (HMO-POS) member who utilizes his/her referred benefit. Most outpatient short-term rehabilitation therapy services, including physical therapy (PT) and occupational therapy (OT) services, are included in capitation.

Above capitation, for the purpose of this policy, refers to the fee-for-service reimbursement that a participating PT/OT provider may receive for rendering PT/OT services to an HMO or HMO-POS member.

Physical therapy (PT) is a medically prescribed treatment for physical disabilities or impairments that result from disease, injury, congenital anomaly, and/or prior therapeutic intervention. PT employs the use of therapeutic exercise and other interventions that focus on locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, and the functional activities of daily living.

Occupational therapy (OT) services are part of a constellation of medically prescribed rehabilitative services designed to improve or restore an individual's physical or mental functioning following disease, injury, or loss of a body part. These skilled treatments aim to provide an individual with the necessary skills for leading an independent life, which can also be referred to as, "the skills for the job of living."

References

Company Benefit Contracts.

Provider Manual for Participating Professional Providers.

Coding

CPT Procedure Code Number(s)
The Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-9), or revenue code that represents the applicable therapy service and the diagnosis code that is representative of the patient's condition appear in one of the following Attachments A-D:

 Attachment A: Hand Therapy Services

 Attachment B: Lymphedema Therapy Services

 Attachment C: Pelvic Floor Therapy Services

 Attachment D: Vestibular Rehabilitation Services
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
N/A
HCPCS Level II Code Number(s)
The Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), International Classification of Diseases (ICD-9), or revenue code that represents the applicable therapy service and the diagnosis code that is representative of the patient's condition appear in one of the following Attachments A-D:

 Attachment A: Hand Therapy Services

 Attachment B: Lymphedema Therapy Services

 Attachment C: Pelvic Floor Therapy Services

 Attachment D: Vestibular Rehabilitation Services
Revenue Code Number(s)
N/A


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Coding and Billing Requirements

Policy History

Revisions From 00.03.06g:
10/01/2025This policy has been identified for the CPT code update effective 10/01/2025 .

The following ICD-10 code has been removed from Attachment C of the policy:
R10.2

The following ICD-10 codes have been added  code has been added to Attachment C of this policy:
R10.20, R10.21, R10.22, R10.23, R10.24

The following ICD-10 codes on Attachment A2 have had narratives been revised in this policy:
S62.90XA, S62.90XB, S62.91XA, S62.91XB, S62.92XA, and S62.92XB

Revisions From 00.03.06f:
10/16/2024This policy has been reissued in accordance with the Company's annual review process.​​
​10/01/2019
​This policy has been identified for the Quarterly Code Update. This version of the policy will become effe​ctive 10/01/2019.

    • The following ICD-10 codes have been deleted from this policy: H81.41, H81.42, H81.43, H81.49
    • The following ICD-10 code has been added to this policy: H81.4

Revisions From 00.03.06e:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT code has been added to this policy:
97763

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

The following CPT code narratives have been revised in this policy:
97760, 97761
10/1/2025
10/6/2025
00.03.06
Claim Payment Policy Bulletin
Commercial
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.