CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Physical and Occupational Services (PT/OT/OMT) Coverage Criteria

Defines coverage, coding, and documentation expectations for physical therapy (PT), occupational therapy (OT), and osteopathic manipulative treatment (OMT) for Blue Cross Blue Shield - Rhode Island members. Applies to providers submitting PT/OT/OMT services for BlueCHiP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPhysical and Occupational Services (PT/OT/OMT) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionInclude a plan of care with specific short- and long-term goals, measurable objectives, expected timeframe, frequency and duration, and update it as the condition changes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

60 daysimprovement expectation

1 hourtypical session length

98925-98929OMT codes covered

97127Therapeutic interventions code

Coverage Criteria

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Medical necessity

Covered when ALL of the following are met:

Medical necessity for PT/OT: Services are medically necessary when performed to meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or therapeutic intervention.

BlueCHiP for Medicare and Commercial Products

Benefits for physical and occupational therapy may differ by group or contract. Refer to the member's Subscriber Agreement or member certificate for the specific physical and occupational therapy benefits and coverage that apply to a patient.

This policy is provided for informational purposes and is not a guarantee of payment or a substitute for clinical judgment. Benefits and eligibility are determined by the member's subscriber agreement or employer agreement, which supersede this policy. If services are determined to be not medically necessary (or are non-covered benefits), providers may not charge the member unless the member has been informed and has agreed in writing in advance to accept financial responsibility.

Coding and Billing

Covered CPT/HCPCS CodesmixedCovered

97127	Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning; executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity; direct (one-on-one) contact (New code effective as of 1/1/2018 replaces deleted code 97532)
97039	Unlisted modality (specify type and time if constant attendance)
98925	Osteopathic manipulative treatment (OMT) 1-2 body regions involved
98926	Osteopathic manipulative treatment (OMT) 3-4 body regions involved
98927	Osteopathic manipulative treatment (OMT) 5-6 body regions involved
98928	Osteopathic manipulative treatment (OMT) 7-8 body regions involved
98929	Osteopathic manipulative treatment (OMT) 9-10 body regions involved

Deleted codesCPTNot Covered

97532

Development of cognitive skills to improve attention, memory, problem solving (deleted 12/31/2017)

Plan of care improvement expectation

Improvement timeframeExpectation of significant functional improvement within 60 days of the initial therapy visits

Plan of care goalsMust include specific short- and long-term goals and measurable objectives

Frequency & durationPlan must state the frequency and duration of treatment

Modalities/exercisesPlan must list the specific modalities and exercises to be used

UpdatesPlan of care should be updated as the patient’s condition changes

Provider Actions and Documentation

Note

Prior authorization requirement

Not applicable.

Note

Provider billing note

When filing claims, include required discipline modifier to indicate therapy type (GO for OT, GP for PT) — see billing modifier callout below.

Documentation Required

Plan of care documentation

The plan of care must document: specific short- and long-term goals with measurable objectives; a reasonable timeframe for expected improvement (typically significant functional improvement within 60 days of initial therapy); frequency and duration of treatment; and the specific modalities and exercises to be used. Update the plan of care as the patient’s condition changes.

Billing Rule

Required discipline modifier — Claims filed without required modifier will deny

Claims filed without the required discipline modifier will deny. Append one of the following modifiers to applicable CPT codes: GO for services delivered under an outpatient occupational therapy plan of care; GP for services delivered under an outpatient physical therapy plan of care. Providers billing with bill types 032X, 033X, and 034X are exempt from appending these modifiers when billing with HCPCS codes for physical and occupational services.

Covered CPT/HCPCS examples: 97127, 97039
OMT codes covered as part of PT/OT benefits: 98925, 98926, 98927, 98928, 98929

Background

Physical therapy uses therapeutic exercise and other interventions to improve posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and the ability to perform functional activities of daily living. Occupational therapy uses goal-directed activities and task-specific training to improve functional performance, including activities of daily living (ADLs), cognitive and perceptual training, and orthotic/prosthetic programs. Habilitative services are health care services that help a person learn or improve skills and functioning for daily living and may include PT or OT when provided by qualified professionals.

Typical outpatient sessions are often defined as up to 1 hour for a treatment and/or evaluation, and plans of care should document specific short- and long-term goals, measurable objectives, frequency and duration, and the expected timeframe for improvement (with an expectation of significant functional improvement generally within 60 days of initial therapy visits).

Definitions

Physical therapy (PT)

DefinitionTreatment of disease or injury by therapeutic exercise and other interventions focused on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and ability to perform functional activities of daily living.

Typical session lengthTypically defined as up to 1 hour of treatment and/or evaluation (or up to 3 PT modalities on a given day)

Common interventionsTherapeutic exercise programs, thermotherapy/cryotherapy/hydrotherapy, electrical stimulation, massage, traction, mobilization techniques, and family education in home exercise programs

Qualified providersMay include MD, DO, physical therapists, occupational therapists, and physical/occupational assistants as allowed by state law

Occupational therapy (OT)

DefinitionRehabilitation therapy using specific tasks or goal-directed activities to improve functional performance, including ADL training, cognitive/perceptual evaluations and training, orthotic/prosthetic programs, and training in adaptive equipment.

Typical session lengthTypically defined as up to 1 hour of treatment and/or evaluation

Common interventionsADL and self-care training, functionally oriented upper-extremity exercise programs, cognitive/perceptual and safety/judgment training, orthotic/prosthetic programs, and family training in home programs

FocusEmphasizes purposeful activities to improve neuromusculoskeletal function and functional performance

Habilitative services

DefinitionHealth care services that help a person learn or improve skills and functioning for daily living; provided by qualified professionals.

ExamplesTherapy for a child who is not walking or talking at the expected age; may include physical, occupational, or speech therapy in outpatient settings for people with disabilities

PurposeTo enable acquisition or improvement of skills and functioning necessary for independent daily living