Commercial

Medical Policy

Notification

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

Notification Issue Date:

Title:

Policy #:

00.03.06f

Policy

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

10/1/2019

Version Issued Date:

10/22/2019

Version Reissued Date: