CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Physical and Occupational Therapy Per-Day Payment Cap

Defines BCBSRI's daily maximum allowable reimbursement policy for physical and occupational therapy services billed by contracted professional providers; applies to BlueCHiP for Medicare and Commercial products and other professional providers under BCBSRI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPhysical and Occupational Therapy Per-Day Payment Cap

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2011

Next Review DateN/A

Key ActionDo not seek prior authorization; prior authorization is not applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

daily capper-day cap applies to combined PT/OT services

evaluation excludedTherapy evaluations reimbursed in addition to daily cap

multiple specialtiesApplies to multiple specialties

2019-11-19Last updated

Per-Day Therapy Reimbursement

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Per-Day Therapy Reimbursement Criteria

Covered when the following rules are met:

ALL of the following

If the combined allowances for all physical and occupational therapy services performed on the same day exceed the per-day allowable maximum, the amount above the maximum will not be reimbursed.
If a physical or occupational therapy evaluation occurs on the same day that physical or occupational treatment/services are performed, reimbursement will be made for both the evaluation and the therapy services performed that day; the evaluation is not included in the daily maximum allowable.
When services are provided on the same day by providers in different specialties (e.g., physical and occupational therapists), both specialties may be reimbursed up to the per-day allowable maximum.

Key Definitions

inv-04: daily maximum allowable reimbursement

DefinitionDaily maximum allowable reimbursement: the per-day cap applied to combined physical and occupational therapy services billed on the same day; amounts above the cap will not be reimbursed.

ScopeApplies to BCBSRI contracted professional providers for BlueCHiP for Medicare and Commercial products and other professional providers.

Application ruleIf the combined allowances for all physical and occupational therapy services performed on the same day exceed the per-day allowable maximum, the amount above the maximum will not be reimbursed.

Multiple specialtiesWhen services are provided on the same day by providers in different specialties (e.g., physical and occupational therapists), both specialties may be reimbursed up to the per-day allowable maximum.

inv-05: therapy evaluation

DefinitionTherapy evaluation: physical or occupational therapy evaluations performed on the same day as treatment are reimbursed in addition to the therapy services and are not counted toward the daily maximum allowable.

Reimbursement ruleIf a physical or occupational therapy evaluation occurs on the same day that treatment/services are performed, reimbursement will be made for both the evaluation and the therapy services performed that day.

Counting toward capEvaluation services are explicitly excluded from the per-day maximum allowable calculation.