CurrentBlue Cross Blue Shield - OklahomaPolicy CPCPO4O

Physical Medicine and Rehabilitation Services

Governs billing, coding, and claims processing requirements for physical medicine and rehabilitation services for Blue Cross Blue Shield - Oklahoma members and providers submitting claims to the Plan.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPhysical Medicine and Rehabilitation Services

Policy CodePolicy CPCPO4O

Change TypeNew policy (split) and annual review

Effective DateJanuary 25, 2024

Next Review Date

Key ActionSubmit accurate documentation and be prepared to provide supporting documentation upon request for claims review.

SourceLink

POLICY UPDATE CHANGES

New Policy: Split from CPCPO16 Chiropractic Care Services.

Annual Review conducted January 12, 2024.

1.0policy version

Jan 25, 2024effective date

Jan 12, 2024approval date

Related policiescross-references

Coverage Criteria for PM&R Services

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Coverage criteria for PM&R services

Services may be covered when documentation and clinical criteria are met:

Services must be skilled in nature and require a qualified healthcare professional; documentation must state delegation details when applicable.

Services must not be maintenance in nature (ongoing care after a condition has stabilized or reached maximum medical improvement).

Services performed must achieve a specific diagnosis-related functional goal with a documented expectation that the member will achieve reasonable improvement over a predictable period of time.

Physical therapy for athletic conditioning is not reimbursable by the Plan.

Specific CPT codes require defined documentation elements: for example, CPT 97110 and 97112 require the specific exercises/activities, the purpose related to function, and start/stop times or direct one-on-one contact time; CPT 97140 requires the area treated, technique, and start/stop times or direct one-on-one contact time.

Timed codes must follow the 8-minute midpoint rule: only direct treatment time is counted, pre/post activities and waiting/resting are excluded, each minute may be counted only once, and recorded start/stop times must be in the medical record.

Reporting time-to-unit thresholds for 15-minute timed codes: 1 unit: >8 through 22 minutes; 2 units: >23 through 37 minutes; 3 units: >38 through 52 minutes; 4 units: >53 through 67 minutes; 5 units: >68 through 82 minutes; 6 units: >83 through 97 minutes; 7 units: >98 through 112 minutes; 8 units: >113 through 127 minutes.

The Plan will not reimburse PTs/OTs or PT/OT assistants for E/M CPT codes 99202-99499.

DME rentals or purchases require a signed prescription/order from the treating qualified healthcare provider that is renewed annually and includes member identification, diagnosis, type of equipment, date, rationale, expected duration, provider information, quantity (if applicable), and legible signature/date.

Customized DME must be specifically constructed to meet an individual member's needs; an invoice should be included when no procedure or HCPCS code exists. Examples of items that do not qualify as customized are adjustable Velcro braces, pull-on elastic braces, and lightweight wheelchairs with added padding. Custom-fitted and custom-fabricated back brace criteria and conditions for necessity are specified; failure to meet these criteria renders such braces experimental/investigational.

Some modalities are considered experimental, investigational, and/or unproven and are not covered; providers should consult the referenced medical policies (e.g., THE803.004, THE803.008, THE803.010, MED201.026) for details.

Coding and Time Units

Common PM&R CPT codes and documentation expectationsCPTCovered

97110	Therapeutic exercises; documentation must include the specific exercises performed, the purpose related to function, and the start and stop times of the treatment or at minimum the direct one-on-one contact time on each individual activity. Exercises should require the skills of a qualified healthcare professional.
97112	Neuromuscular reeducation; documentation must include the specific exercises/activities performed, the purpose related to function, and the start and stop times of the treatment or at minimum the direct one-on-one contact time spent on each individual activity. Appropriate for neuromuscular diagnoses (e.g., post-CVA, Parkinson's, cerebral palsy, MS); not appropriate for acute musculoskeletal problems or soft tissue mobilization.
97140	Manual therapy; documentation must include the area being treated, the therapy technique being used, and the start and stop times of the treatment or at minimum the direct one-on-one contact time spent on each individual activity. Should require the skills of a qualified healthcare professional; not interchangeable with codes 98940-98942.
97530	Therapeutic activities; documentation must include the area being treated, the specific activity or technique being used, and the start and stop times of the treatment or at minimum the direct one-on-one contact time spent on each individual activity. Activities should require the skills of a qualified healthcare professional.

15-minute unit time thresholds

1 unit> 8 minutes through 22 minutes

2 units> 23 minutes through 37 minutes

3 units> 38 minutes through 52 minutes

4 units> 53 minutes through 67 minutes

5 units> 68 minutes through 82 minutes

6 units> 83 minutes through 97 minutes

7 units> 98 minutes through 112 minutes

Documentation and Claim Review Requirements

Documentation Required

Submit accurate documentation and respond to documentation requests

Providers must submit accurate, complete documentation for services rendered and bill using valid HIPAA-approved code sets; the Plan may request supporting documentation and will review claims against benefit terms, provider contracts, medical and coding policies. Failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Use valid HIPAA-approved code sets (CPT, HCPCS, ICD-10, NDC, DRG) and follow industry-standard coding guidelines.
Be prepared to provide supporting documentation upon request; submit additional documentation when requested.
Claims are subject to code edit protocols, plan/contract terms, medical policies, and coding software logic and may be reviewed case-by-case.

Definitions

Durable Medical Equipment (DME)

DefinitionEquipment 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 useUsed to provide medical benefit in the home setting such as mobility or respiratory support.

DistinctionDME is distinct from supplies or non-durable items due to repeated-use and medical purpose.

Home Setting

Included locationsMember's dwelling (house, apartment), a relative's home if the member lives there, or other residences used as a home.

Facility examplesAssisted living, retirement homes, or homes for the aged are considered home settings.

ApplicabilityHome setting definition applies when determining appropriateness of DME and home-based services.

Modalities (Supervised vs. Constant Attendance)

Modalities definedPhysical agents applied to produce a therapeutic change (thermal, acoustic, light, mechanical, electrical).

Supervised modalitiesProvider oversight required but not necessarily at the patient's side; these are procedure/service based and units are always one (1).

Constant attendance modalitiesProvider must be with the patient; time-based reporting where one unit equals 15 minutes and subject to the 8-minute midpoint rule.

Prescription/Order

DefinitionA written order/prescription from a treating provider that documents the need for DMEPOS and/or services.

AvailabilityThe prescription/order must be readily available if requested for DME rentals or purchase.

PurposeDocuments medical necessity and supports claims for DME and related services.

Qualified Healthcare Professional (QHP)

DefinitionIndividual 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 professional service.

RolePerforms skilled services and documents delegation when applicable to support medical necessity and billing.

ScopeQHP status determines who may appropriately deliver and report PM&R services under this policy.