CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP040

Physical Medicine and Rehabilitation Services

Governs billing, coding, documentation, and reimbursement guidance for physical medicine and rehabilitation services for BCBSOK members and participating providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPhysical Medicine and Rehabilitation Services

Policy CodePolicy CPCP040

Change TypeNo material change

Effective DateMar 28, 2023

Next Review DateN/A

Key ActionSubmit accurate documentation and supporting records when requested; providers are urged to supply additional documentation to support services billed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

CPCP040Policy

8-minuteTimed code rule

97110/97112/97140/97530Common CPT examples

Mar 28, 2023Effective

5Related policies

Coverage Criteria and Billing Rules

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PM&R coverage criteria and billing rules

Conditions required for PM&R services to be considered for coverage:

ALL of the following

The therapy must be of a skilled nature and require the services of a qualified healthcare professional. When services are delegated, documentation must include details of what was delegated and who performed the service(s).
The services/therapy must not be maintenance in nature; ongoing physical medicine treatment after a condition has stabilized or reached a clinical plateau (maximum medical improvement) does not qualify as necessary and would be considered 'maintenance care'.
Services performed must achieve a specific diagnosis-related goal.
There must always be a documented expectation that the member will, in fact, achieve reasonable improvement over a predictable period of time for the services to be eligible for reimbursement.
Physical therapy for performance of athletic conditioning is not reimbursable by the Plan.

Coding, Timed Unitization, and Related Systems

Common PM&R CPTs and E/M guidanceCPTCovered

97110	Therapeutic exercises: Documentation must include the specific exercises performed, the purpose related to function, and start/stop times or direct one-on-one contact time; exercises should require skills of a qualified healthcare professional.
97112	Neuromuscular reeducation: Documentation must include specific exercises/activities, purpose related to function, and start/stop times or direct one-on-one contact time; appropriate for neuromuscular diagnoses (e.g., post-CVA, Parkinson's, cerebral palsy, MS); not appropriate for acute musculoskeletal stabilization; not for soft tissue mobilization.
97140	Manual therapy: Documentation must include the area treated, the therapy technique used, and start/stop times or direct one-on-one contact time; should not be used interchangeably with codes 98940-98942 or 97124.
97530	Therapeutic activities: Documentation must include the area being treated, the specific activity/technique used, and start/stop times or direct one-on-one contact time; activities should require the skills of a qualified healthcare professional.
99202-99499	Evaluation and Management (E/M) codes: Complete CPT guidelines must be met; the Plan will not reimburse Physical/Occupational Therapists or Therapy Assistants for CPT E/M codes 99202-99499.

DME supply coding examplesHCPCSCovered

A4595	Electrical stimulator supplies (example recommended for TENS replacement products).
A4556	Electrodes (example listed as not preferred when billing replacement TENS products separately).
A4557	Leads (example listed).
A4558	Conductive paste or gel (example listed).
A4630	Replacement batteries (example listed).

Referenced coding systemsmixed

CPT	Current Procedural Terminology (AMA)
HCPCS	Healthcare Common Procedure Coding System

Timed code unitization — 8-minute rule / 15-minute units guidance

Unitization ruleUse the 8-minute rule for timed services billed in 15-minute units: 1 unit = ≥8 to 22 minutes; subsequent unit ranges defined through 8 units (≥113–127 minutes).

Counting timeReport only actual treatment time; exclude pre/post delivery activities, resting/waiting time, and time must be recorded with start/stop times in the medical record.

One-minute counted onceEach minute of treatment time may be counted only once; time spent attending a supervised modality cannot be counted for another service concurrently.

Minimum reportable durationDo not report a direct treatment service if a single attended modality or therapeutic procedure is performed for less than 8 minutes in a day.

Example unit intervalsUnits by minutes: 1 unit ≥8–22; 2 units ≥23–37; 3 units ≥38–52; 4 units ≥53–67; 5 units ≥68–82; 6 units ≥83–97; 7 units ≥98–112; 8 units ≥113–127.

Provider Responsibilities and Related Policy Guidance

Documentation Required

Documentation requests and discretionary interpretation

If a conflict arises between a Clinical Payment and Coding Policy ('CPCP') and any plan document under which a member is entitled to Covered Services, the plan document will govern. If a conflict arises between a CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract will govern. 'Plan documents' include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. BCBSOK may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. BCBSOK has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.

Providers are responsible for submission of accurate documentation of services performed.
Providers must submit claims using HIPAA-approved code sets and appropriate code combinations (CPT®, HCPCS, ICD-10, NDC, DRG, etc.).
Claims are subject to code edit protocols and claim review including benefit coverage, provider contract language, medical policies, CPCPs, and coding software logic.
Upon request, providers should submit any additional documentation to support services billed.

Note

Related policy guidance (see internal CPCP policies)

See related Clinical Payment and Coding Policies for additional guidance on billing, coding and documentation requirements.

CPCP016 Chiropractic Care Services
CPCP023 Modifier Reference Policy
CPCP029 Medical Record Documentation
CPCP033 Telemedicine and Telehealth Services
CPCP036 Paravertebral Facet Injection Procedure Coding & Billing Policy

Definitions

Durable Medical Equipment (DME) definition

DefinitionDurable Medical Equipment (DME): Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful in the absence of illness or injury, and is appropriate for use in the home.

Typical characteristicsReusable, medically necessary, and intended for home use rather than general everyday use.

DocumentationA prescription/order must document need for DME when requested for rental or purchase (see policy for required elements).

Home Setting definition

DefinitionHome Setting: the member's dwelling (house, apartment, or private living space), a relative's home if the member lives there, another residence used as a home, or a home for the aged/retirement/assisted living facility.

ApplicabilityDefines locations considered ‘home’ for DME and in-home services eligibility and documentation purposes.

Use in policyUsed to determine appropriateness of DME and home-based therapy services under plan rules.

Modalities (Supervised / Constant Attendance) definition

DefinitionModalities: any physical agent applied to produce a therapeutic change to biological tissue (e.g., thermal, acoustic, light, mechanical, electrical).

Supervised modalityProvider watches over the application but need not be at the patient's side; these are procedure/service based and units are always one (1).

Constant attendanceProvider must be with the patient at all times; these are time-based modalities where one unit = 15 minutes.

Prescription/Order definition

DefinitionPrescription/Order: a written communication from a treating provider documenting the need for DMEPOS and/or services; must be available if requested for rentals or purchases.

Required elements (policy reference)Prescription must include member identification, diagnosis, equipment description, rationale, dates/quantity, provider information, and signature (see policy for full list).

RetentionPrescriptions/orders must be readily available to support DME rental or purchase claims when requested by the plan.

Qualified Healthcare Professional (QHP) definition

DefinitionQualified Healthcare Professional (QHP): an individual qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that service.

ScopeQHPs perform skilled services and their credentials determine who may provide and document skilled PM&R services.

Documentation roleQHP must sign orders/prescriptions and documentation when required for DME or skilled services.

Therapeutic Procedure definition

DefinitionTherapeutic Procedure: the application of clinical skills and/or services intended to improve function.

ExamplesIncludes procedures documented as therapeutic interventions (see code tables for common CPT examples).

Billing noteTimed therapeutic procedures follow the reporting and unitization rules (e.g., 8-minute rule) when applicable.

UsePolicy requires use of current CPT codes effective on the date of service for coding and billing.

Trademark/copyrightCPT is an AMA- owned, copyrighted and registered trademark resource referenced by the plan.

Healthcare Common Procedure Coding System (HCPCS) reference

ReferenceHealthcare Common Procedure Coding System (HCPCS) is referenced by the plan for coding DME, supplies, and related items.

UsePolicy directs use of HCPCS codes where applicable (e.g., DME supply examples listed in coding tables).

Relation to CPTHCPCS complements CPT coding for non-physician services and DMEPOS items under this policy.