Commercial

Medical Policy

Notification

Outpatient Short-Term Rehabilitation Services Included in Capitation

Notification Issue Date:

This policy has been identified and updated for the CPT code update effective 01/01/2020.

The following CPT code has been termed from this policy: 97127.

The following HCPCS code has been termed from this policy: G0515.

The following CPT codes have been added to this policy: 97129 and 97130.

Title:

Outpatient Short-Term Rehabilitation Services Included in Capitation

Policy #:

00.03.03i

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

Policy

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 providers (PCPs) of Health Maintenance Organization (HMO) or HMO Point-of-Service (POS) products members who utilize their referred benefit and who are enrolled in one of the following:

NJ-based Commercial HMO products or HMO Point-of-Service (POS) products
PA-based Commercial HMO products or HMO Point-of-Service (POS) products

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.

Coding

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.

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 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.

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Revisions From 00.03.03i:

09/25/2023

This version of the policy will become effective 09/25/2023. This policy number 00.03.03i has been updated to remove the following CPT code from the Outpatient short-term rehabilitation services included in capitation and allow for fee-for-service reimbursement consideration.

The following CPT code has been removed from Attachment A of this policy:

97610

Revisions From 00.03.03h:

01/01/2020

Revisions From 00.03.03g:

01/01/2018

This 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:

9/25/2023

Version Issued Date:

9/25/2023

Version Reissued Date: