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    Are there any physical therapy services that are considered reimbursable in a comprehensive outpatient rehabilitation facility (CORF) setting but are not considered reimbursable in an outpatient physical therapy (OPT) or rehabilitation agency?

    No, however OPTs and CORFs are different provider types and submit claims on different types of bills. In addition, they are not part of an outpatient hospital therapy department. 

    An OPT is defined as a provider of service with an agreement to furnish outpatient therapy services to beneficiaries. The services must be reasonable and necessary with a potential for improvement. Only restoration therapy is covered. The beneficiary must be under the care of a physician. The facility agrees that they will not charge the beneficiary for covered services that Medicare should pay. OPTs use a 74x type of bill when submitting claims to Medicare. 

    A CORF is a facility that is primarily engaged in providing diagnostic, therapeutic and restorative services to outpatients for the rehabilitation of the injured and disabled or patients recovering from an illness. The CORF must provide a comprehensive, coordinated skilled rehabilitation program for its patients that include, at minimum, CORF physicians’ services, physical therapy services, and social or psychological services. The facility must have adequate space and equipment necessary for any of the services provided. In general, all services must be furnished on the premises of the CORF. The only exception is home evaluations. CORFs use a 75x type of bill when submitting claims to Medicare. 

    Another difference between CORFs and OPTs

    For a CORF, the referring physician must review the plan of treatment every 60 days. However, an OPT must have the physician certify the plan of care every 90 days. For outpatient hospital-based therapy departments, re-certification for therapy should be performed every 90 days; however, it is acceptable for re-certification to be performed every 60 days.

     

    References

    Can lifetime reserve (LTR) days be used automatically if the beneficiary elects not to use them?

    No, hospitals are required to notify patients who have used or will use 90 days of benefits that they can choose not to use their reserve days for all or part of a stay. The hospital notice should be given when the beneficiary has five regular coinsurance days left and is expected to be hospitalized beyond that period. If the hospital discovers the patient has fewer than five regular coinsurance days left, it should immediately notify the patient of this option. The hospital should notate when it informed the patient of this option.

     

    Reference

    Do First Coast medical review nurses deny chiropractic services based on medical necessity?

    When your office receives a request for medical records to substantiate the chiropractic services you rendered and billed to Medicare, our nurse reviewers review the documentation and verify all the required documentation has been met. If you met the documentation requirements, the nurse reviewers will send the documentation to a chiropractic consultant to determine the medical necessity of the services. If you did not meet the documentation requirements, the nurse reviewers will deny the services based on the lack of documentation.

    Does Medicare cover PHP for substance use disorders?

    Yes. Medicare covers partial hospitalization program (PHP) services for the treatment of substance use disorders (SUDs). Specifically, notwithstanding the requirement that PHP services are provided in lieu of inpatient hospitalization, CMS considers services for the treatment of SUD and behavioral health to be consistent with the statutory and regulatory definitions of PHP services.

     

    References

    How should MDPP suppliers submit claims for MDPP sessions delivered via distance learning to patients located in other states?

    MDPP suppliers submit all claims for MDPP services to their MAC, regardless of where the patient is located. 

    The claims submission process will be the same for MDPP sessions delivered via distance learning as for MDPP sessions delivered in-person.

    MDPP suppliers will use “Other” (99) as their place of service (POS) code for sessions delivered via distance learning and HCPCS code G9887. 

    For MDPP billing, claims may list the currently enrolled practice location (not the coach’s home address) as the POS.

     

    References

    My claim was denied because the patient was in a skilled nursing facility (SNF) and consolidated billing applies. What is included in consolidated billing?

    One of the provisions of the Balanced Budget Act (BBA) of 1997 (Section 4432b) requires consolidated billing for SNFs. The consolidated billing requirement confers on the SNF the billing responsibility for the entire package of care residents receive during a covered Part A SNF stay, as well as physical, occupational, and speech therapy services received during a non-covered stay.

    A limited number of services are specifically excluded from consolidated billing and therefore separately payable under Part B. These exceptions, as well as additional information concerning SNF consolidated billing, can be found on the CMS website at the CMS SNF consolidated billing webpage.

    See additional information in our SNF overlap FAQ.

     

    Reference 

    Should a facility use condition code 44 on a claim if the admitting physician decides the patient should be in observation rather than an inpatient setting?

    (Additionally, when the physician decides the patient should be in observation without prompting by the utilization review (UR) committee or case management and prior to the discharge of the patient and submission of the claim.)

    No. When a physician orders a patient to be placed under observation, the patient's status is outpatient. The purpose of observation is to determine the need for further treatment or for inpatient admission.

    Condition code 44 is used when an inpatient admission is being changed to outpatient. According to the CMS IOM Pub. 100-04, Medicare Claims Processing Manual, Chapter 1 -- General Billing Requirements, condition code 44 is:

    • For use on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization review performed before the claim was originally submitted, the hospital determined the services did not meet its inpatient criteria.
    • Note: For Medicare, the change in patient status from inpatient to outpatient is made prior to discharge or release while the patient is still a patient of the hospital.
    • Additionally, concurrence of the UR committee and the physician must be documented in the medical record.

     

    Reference

    We submitted X-ray reports with subsequent chiropractic visits, but they denied as out of date, why?

    X-rays must be reasonably proximate to the initiation of a course of treatment. Unless more specific X-ray evidence is warranted, an X-ray is considered reasonably proximate if it was taken no more than 12 months prior to or 3 months following the initiation of a course of chiropractic treatment. 

    In certain cases of chronic subluxation (e.g., scoliosis), an older X-ray may be accepted provided the beneficiary's record indicates the condition existed longer than 12 months and there is a reasonable basis for concluding the condition is permanent. 

    You may use a previous computed tomography (CT) scan and/or magnetic resonance imaging (MRI) of the spine in lieu of an X-ray when it demonstrates a subluxation of the spine. The timeframe specified for X-rays is applicable for MRIs and CT scans. 
     

    What are Medicare’s guidelines regarding use of an advance beneficiary notice of noncoverage (ABN) in relation to ambulance services?

    The CMS Medicare Claims Processing Manual states:

    Ambulance transports

    Emergency or urgent situations: In general, a notifier may not issue an ABN to a beneficiary who has a medical emergency or is under similar duress. Forcing delivery of an ABN during an emergency may be considered coercive. ABN usage in the ER may be appropriate in some cases where the beneficiary is medically stable with no emergent health issues.

    Non-emergent / urgent ambulance transport: If the provider or supplier wants to transfer liability to the beneficiary, issuance of the ABN is mandatory for ambulance transport services if all of the following three criteria are met: 

    1. The service being provided is a Medicare covered ambulance benefit under §1861(s)(7) of the SSA and regulations under this section as stipulated in 42 CFR §410.40 -.41
    2. The health care provider or supplier believes that the service may be denied, in part or in full, as “not reasonable and necessary” under §1862(a)(1)(A) for the beneficiary on that occasion; and
    3. The ambulance service is being provided in a non-emergency situation. (The patient is not under duress.) 

    ABN issuance is mandatory only when a beneficiary’s covered ambulance transport is modified to a level that is not medically reasonable and necessary and will incur additional costs. If an ambulance transport is statutorily excluded from coverage because it fails to meet Medicare’s definition of the ambulance benefit, a voluntary ABN may be issued to notify the beneficiary of his/her financial liability as a courtesy.

     

    Reference

    What is modifier AT and when do we report it?

    Modifier AT (active treatment) defines the difference between active treatment and maintenance treatment.

    The AT modifier is required under Medicare billing to receive reimbursement for CPT codes 98940 - 98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active or corrective treatment (acute and chronic care).

    Every chiropractic claim for 98940, 98941 and 98942, should include the AT modifier if active or corrective treatment is being performed. Claims that do not contain modifier AT will deny.

    Do not use modifier AT for maintenance therapy. 
     

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