Humana Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) - Medicare Advantage Form

Please refer to CMS website for the most current applicable National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/CMS Online Manual System/ Transmittals. Type Title ID Number Jurisdiction Medicare Administrative Applicable States/Territories Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 2 of 22 Contractors (MACs) Internet- Only Manuals (IOMs) Internet- Only Manuals (IOMs) Internet- Only Manuals (IOMs) Internet- Only Manuals (IOMs) Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12 Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 §40 – Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage §220 – Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech- Language Pathology Services) Under Medical Insurance §220.1 – Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech- Language Pathology Services §220.1.2 – Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech- Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 3 of 22 Internet- Only Manuals (IOMs) Internet- Only Manuals (IOMs) Internet- Only Manuals (IOMs) Internet- Only Manuals (IOMs) Internet- Only Manuals (IOMs) Internet- Only Manuals (IOMs) Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15 Language Pathology Services §220.2 – Reasonable and Necessary Outpatient Rehabilitation Therapy Services §220.3 – Documentation Requirements for Therapy Services §230 – Practice of Physical Therapy, Occupational Therapy, and Speech- Language Pathology §230.1 – Practice of Physical Therapy §230.2 – Practice of Occupational Therapy §230.5 – Physical Therapy, Occupational Therapy and Speech- Language Pathology Services Provided Incident to the Services of Physicians and Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 4 of 22 Non-Physician Practitioners (NPP) Acupuncture for Chronic Lower Back Pain (cLBP) Diathermy Treatment Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders Heat Treatment, Including the Use of Diathermy and Ultra- Sound for Pulmonary Conditions 30.3.3 150.5 270.1 150.8 240.3 Nerve Blocks for Peripheral Neuropathy Billing and Coding: Nerve Blocks for Peripheral Neuropathy L35222 A57589 Outpatient Physical and Occupational Therapy Services Billing and Coding: Outpatient Physical and Occupational Therapy Services Pain Management Billing and Coding: Pain Management Peripheral Nerve Blocks Billing and Coding: Peripheral Nerve Blocks Nerve Blocks for Peripheral Neuropathy L33631 A56566 L33622 A52863 L36850 A57452 L35249 A57663 NCD NCD NCD NCD NCD LCD LCA LCD LCA LCD LCA J5 - Wisconsin Physicians Service Insurance Corporation J8 - Wisconsin Physicians Service Insurance Corporation J6 - National Government Services, Inc. (Part A/B MAC) JK - National Government Services, Inc. (Part A/B MAC IA, KS, MO, NE IN, MI IL, MN, WI CT, NY, ME, MA, NH, RI, VT J15 - CGS Administrators, KY, OH Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 5 of 22 Billing and Coding: Nerve Blocks for Peripheral Neuropathy Outpatient Physical and Occupational Therapy Services L34049 A57067 LLC (Part A/B MAC) Billing and Coding: Outpatient Physical and Occupational Therapy Services Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma Billing and Coding: Injections - Tendon, Ligament, Ganglion Cyst, Tunnel Syndromes and Morton's Neuroma Nerve Blockade for Treatment of Chronic Pain and Neuropathy LCD LCA Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy Billing and Coding: Medical Necessity of Therapy Services Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing Nerve Blockade for Treatment of Chronic Pain and Neuropathy Billing and Coding: Nerve Blockade for Treatment of Chronic Pain and Neuropathy Billing and Coding: Medical Necessity of Therapy Services Billing and Coding: Therapy Evaluation, Re-Evaluation and Formal Testing LCD LCA L34218 A57079 L35456 A56034 A53304 A53309 L35457 A52725 A52775 A52773 JE - Noridian Healthcare Solutions, LLC CA, HI, NV, American Samoa, Guam, Northern Mariana Islands JF - Noridian Healthcare Solutions, LLC AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 6 of 22 Nerve Blocks and Electrostimulation for Peripheral Neuropathy Billing and Coding: Nerve Blocks and Electrostimulation for Peripheral Neuropathy LCD LCA Outpatient Occupational Therapy Billing and Coding: Outpatient Occupational Therapy Outpatient Physical Therapy Billing and Coding: Outpatient Physical Therapy Peripheral Nerve Blocks Billing and Coding: Peripheral Nerve Blocks LCD LCA Description §1861 of the Social Security Act L37642 A56731 L34427 A53064 L34428 A53065 JJ - Palmetto GBA (Part A/B MAC) JM - Palmetto GBA (Part A/B MAC) AL, GA, TN NC, SC, VA, WV L33933 A57788 JN - First Coast Service Options, Inc. (Part A/B MAC) FL, PR, U.S. VI Physical therapy (PT) is the treatment of disorders or injuries using physical methods or modalities. A PT modality is often defined as any physical agent applied to produce therapeutic changes to biologic tissues. Modalities that are generally accepted for use include exercises, thermal, cold, ultrasonic or electric energy devices. Due to the passive nature of therapeutic modalities, they are generally used to enable the individual to take part in active aspects of therapy. PT may be indicated for treatment of muscle weakness, limitations in the range of motion, neuromuscular conditions, musculoskeletal conditions, lymphedema and for selected training of an individual in specific techniques and exercises for their own continued use at home. Therapeutic procedures are intended as a means of effecting change using clinical skills and/or techniques and/or services whose goal is the improvement of function. PT procedures in general include therapeutic exercises and joint mobilization. These have generally been shown to be one set of effective means of treating aspects of many musculoskeletal conditions. Medically necessary PT services must be restorative in nature or for the specific purposes of designing and teaching a maintenance program for the individual to carry out at home. The services must also relate to a Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 7 of 22 written treatment plan and be of the level of complexity that requires the judgment, knowledge and skills of a physical therapist (or medical doctor/doctor of osteopathy) to perform and/or directly supervise. The amount, frequency and duration of PT services must be seen as medically appropriate for the specific treatment regimen and be performed by a physical therapist. A qualified physical therapist, for benefit coverage purposes, is an individual who is licensed as a physical therapist by the state in which he or she is practicing. A physical therapist assistant (PTA) is an individual who is licensed as a PTA, if applicable, by the state in which he or she is practicing. The services of a PTA must be supervised by a licensed physical therapist at a level of supervision determined by state law or regulation. Occupational therapy (OT) is a form of rehabilitation therapy involving the treatment of neuromuscular and other dysfunction through the use of specific tasks or goal-directed activities to improve an individual’s functional performance. Therapy programs are designed to improve the individual’s quality of life through the recovery of specific competencies, maximizing independence and the prevention of specific illness or disability. OT includes helping an individual learn or relearn specific daily living skills (eg, basic activities of daily living [ADL]) such as dressing, eating, personal hygiene, self-care and mobility/transfers. OT also includes specific task oriented therapeutic activities designed to restore physical function of the shoulder, elbow, wrist and/or hand that has been lost as a result of illness or injury. Occupational therapy can include the design, fabrication and fitting/maintenance of orthotics and related self-help devices including the fitting/fabrication of splints for the upper extremity. Medically necessary OT services must relate to a written treatment plan and be of the level of complexity that requires the judgment, knowledge and skills of an occupational therapist (or medical doctor/doctor of osteopathy) to perform and/or directly supervise these services. The amount, frequency and duration of occupational therapy services must be medically appropriate for the specific treatment regimen and be performed by an occupational therapist. A qualified occupational therapist, for benefit coverage purposes, is an individual who is licensed as an occupational therapist by the state in which he or she is practicing. An occupational therapy assistant (OTA) is an individual who is licensed as an OTA, if applicable, by the state in which he or she is practicing. The services of an OTA must be supervised by a licensed occupational therapist at a level of supervision determined by state law or regulation. Coverage Determination Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare. Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 8 of 22 Please refer to the above Medicare guidance for outpatient rehabilitation therapy (physical therapy, occupational therapy) services/items. In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the criteria contained in the following: LCD - Outpatient Physical and Occupational Therapy Services (L33631) (cms.gov) This LCD is adopted to provide recommendations for jurisdictions without an LCD and intended to assist qualified professionals/auxiliary personnel in documenting to support both the medical necessity and the skilled nature of the therapy services provided. General PT Guidelines28 1. PT services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed physical therapist or under his/her supervision. Services normally considered a routine part of nursing care are not covered as PT (i.e., turning patients to prevent pressure injuries, walking a patient in the hallway postoperatively or ambulation without gait training). 2. Covered PT must be furnished while the individual is or was under the care of a physician. Services must relate directly and specifically to a written plan of treatment regimen established by the physician or NPP after any necessary consultation with the qualified physical therapist, or by the physical therapist providing the services and must be reasonable and necessary to the treatment of the individual's illness or injury. 3. In order for the plan of treatment to be covered, it must address a condition for which PT is an accepted method of treatment as defined by standards of medical practice. Also, the plan of treatment must be for a condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer be considered reasonable and necessary and are excluded from coverage. 4. PT is only covered when it is rendered under a written plan of treatment established by the physician, NPP or the qualified physical therapist, to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or NPP should periodically review the plan of treatment. 5. The physician or NPP and/or therapist must document the patient's functional limitations in terms that are objective and measurable. PT Evaluation28 Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted, e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the POC, including goals and the selection of interventions. The time spent in evaluation does not count as treatment time. Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 9 of 22 1. The initial examination has the following components: a. The patient history to include prior level of function b. Relevant systems reviews c. Tests and measures d. Current functional status (abilities and deficits) 2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent of loss of function, social considerations, and the patient's overall physical function and health status. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Physical therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, disability, the living environment, and the social supports. 3. Initial evaluations or re-evaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized. 4. Re-evaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient's condition or functional status. Some regulations and state practice acts require re-evaluation at specific intervals. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services. 5. A re-evaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued. General OT Guidelines25 1. OT services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed OT or under his/her supervision. Services normally considered a routine part of nursing care are not covered as OT (i.e., provide ADLs for patient with no rehabilitation potential). 2. In order for the plan of treatment to be covered, it must address a condition for which OT is an accepted method of treatment as defined by standards of medical practice. Also, the plan of treatment must be for a condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness or injury it is determined that the treatment is not rehabilitative or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer be considered reasonable and necessary and are excluded from coverage. 3. Covered OT services must be furnished while the individual is or was under the care of a physician. Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 10 of 22 Services must relate directly and specifically to a written plan of treatment. The plan of treatment should address specific therapeutic goals, for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or NPP should periodically review the plan of treatment. 4. The physician, NPP and/or therapist must document the patient's functional limitations in terms that are objective and measurable. OT Evaluation and OT Re-evaluation25 Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions, for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted, e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the POC, including goals and the selection of interventions. The time spent in evaluation does not count as treatment time. 1. The initial examination has the following components: a. The patient history to include prior level of function b. Relevant systems review c. Tests and measures d. Current functional status (abilities and deficits) e. Evaluation of patient's, physician's, NPP's and as appropriate the caregiver's goals 2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, and the patient's overall physical and cognitive health status. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. OTs also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, disability, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment. 3. Initial evaluations or re-evaluations may be determined reasonable and necessary, even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized. 4. Re-evaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient's condition or functional status that was not anticipated in the POC. Some regulations and state practice acts require re-evaluation at specific intervals. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services. OTAs may assist the OT in a re-evaluation within their scope of practice by gathering objective data, tests, Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 11 of 22 measurements, etc.; however, the OT must actively and personally participate in the re-evaluation and is responsible for the assessment and the POC. 5. A re-evaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued. The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy. Coverage Limitations US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage The following services will not be considered medically reasonable and necessary: • Diathermy or ultrasound heat treatments for asthma, bronchitis, or any other pulmonary condition. Refer to the NCD Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions (240.3). • Dry needling for any condition other than chronic low back pain. Refer to the NCD Acupuncture for Chronic Lower Back Pain (cLBP) (30.3.3).14,15,19,29,31,34 • Nerve blocks with or without the use of electrostimulation, and the use of electrostimulation alone for the treatment of multiple neuropathies or peripheral neuropathies caused by underlying systemic diseases.20,21,22,23,24,30,31 Use of physical medicine and rehabilitation CPT/HCPCS codes (97032, 97139, G0282, G0283) for treatment of neuropathies or peripheral neuropathies caused by underlying systemic diseases is inappropriate.7,8,9,15,16 A review of the current medical literature shows that there is no evidence to determine that these services are standard medical treatments. There is an absence of randomized, blinded clinical studies examining benefit and long-term clinical outcomes establishing the value of these services in clinical management. Services which do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For Example, services related to activities for the general good and welfare of patients, such as general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation, do not constitute (covered) therapy services for Medicare purposes.11 Services related to recreational activities such as golf, tennis, running, etc., are also not covered as therapy services.26,27 Outpatient Rehabilitation (Physical Therapy, Occupational Therapy) Page: 12 of 22