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Claim Payment Policy Bulletin

Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
00.01.68b

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 837i form, for members enrolled in all Company products.

Multiple Procedure Payment Reduction (MPPR) guidelines apply when multiple physical, occupational, and speech therapy services designated as Always Therapy are reported by the same outpatient facility provider, for the same individual, on the same date of service. Refer to Attachment A of this policy for services that are designated as Always Therapy services.

MPPR is applied when more than one unit or procedure code is provided, regardless of whether the services are within one therapy discipline or multiple disciplines (i.e., physical, occupational, or speech therapy). 

The hierarchy for MPPR guidelines is set forth below:

  • ​​100 percent of the provider's applicable contracted rate of one unit of the procedure code with the highest total allowance is eligible for reimbursement consideration.
  • Each subsequent unit or procedure code is eligible for reimbursement at 50 percent of the provider's applicable contracted rate.

MPPR 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

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.

BILLING REQUIREMENTS

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

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


Guidelines

This claim payment rationale applies only to the procedure codes addressed in Attachment A of this policy and does not apply to any other code and/or code and modifier combinations. Claims are processed according to the statements in this policy. When a medical policy on this topic also exists, the medical necessity criteria listed in the medical policy must 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

The Centers for Medicare & Medicaid Services (CMS) applies a multiple procedure payment reduction (MPPR) to certain physical, occupational, and speech therapy services that are designated as Always Therapy.

Always Therapy services 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.

In accordance with CMS, the Company has established claims processing guidelines to apply multiple procedure payment reduction to CMS designated Always Therapy services. 

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

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 00.01.68b:
07/01/2024

Thi​s version of the policy will become effective 07/0​1/2024. Policy number 00.01.68b has been updated to communicate the Company's reimbursement methodology. 

 

The Company's reimbursement methodology has been revised from applying MPPR at the procedure code level only to include the procedure code or units of service.  


The following CPT coding changes were made in accordance with the Centers for Medicare and Medicaid Services (CMS) Always Therapy CY 2024 code list:
 

  • Codes 97550 and 97552 have been deleted.
  • Codes 92605, 92606, 92618, and 97010 have been added.​



Revisions From 00.01.68a:
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 00.01.68:
09/01/2019This 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.

07/01/2024
07/01/2024
N/A
00.01.68
Claim Payment Policy Bulletin
Commercial
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No