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:
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.