Physicians/NPPs, independent physical therapists, and independent occupational therapists may bill for physical therapy services using the CPT physical medicine and rehabilitation codes. For evaluations/re-evaluations, physical therapists should use CPT code 97001 and CPT code 97002, and occupational therapists should use CPT code 97003 and CPT code 97004. For evaluation/re-evaluations physician/NPP should report the appropriate E&M code.
Full Answer
What is a rehab agency?
Jan 01, 2021 · Washington Apple Health (Medicaid) Outpatient Rehabilitation Billing Guide January 1, 2021
Is a rehab agency better than a private practice?
• GP Services delivered under an outpatient physical therapy plan of care. 1. List the appropriate procedure code for the service performed, include any necessary modifiers. a. PT/OT/SPL services personally performed by a qualified professional in their office location or a beneficiary’s home should be reported to Medicare under the
Does Medicare cover outpatient PT,OT,and SLP services?
Dec 01, 2021 · Rehabilitation Agency - An agency that provides an integrated, multidisciplinary program designed to upgrade the physical functions of handicapped, disabled individuals by bringing together, as a team, specialized rehabilitation personnel. Clinic - A facility established primarily for the provision of outpatient physicians’ services.
Do you need rehab agency certification?
Aug 14, 2017 · Outpatient Rehabilitation . Billing Guide . August 14, 2017 . Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between this document and an agency rule arises, the agency rules apply.
What is the CPT code for outpatient rehab?
For evaluations/re-evaluations, physical therapists should use CPT code 97001 and CPT code 97002, and occupational therapists should use CPT code 97003 and CPT code 97004. For evaluation/re- evaluations physician/NPP should report the appropriate E&M code.Oct 1, 2011
Where do you put the KX modifier?
The KX modifier is appended on claims at or very close to the $1920 cap, and should not applied from the first visit, even if the therapist knows that the cap will likely be exceeded. At least one MAC has notified therapists that a pattern of early application of the KX modifier may be consider an abuse practice.Jan 14, 2014
What is the CQ modifier?
The modifiers are defined as follows: CQ modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant. CO modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.Nov 11, 2021
How do you use the KX modifier?
The KX modifier, described in subsection D., is added to claim lines to indicate that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.
Why is KX modifier used?
Use of the KX modifier indicates that the supplier has ensured coverage criteria for the billed is met and that documentation does exist to support the medical necessity of item. Documentation must be available upon request.May 4, 2018
Is KX modifier still valid?
Therapists should continue to affix the KX modifier to all medically necessary services above the designated limit ($2,010 in 2018), thus signaling Medicare to pay the claim. That means you must continue to track your patients' progress toward the threshold so you know when to affix the modifier.Oct 8, 2018
Which modifier goes first GP or CQ?
When applicable, report the CQ modifier on the claim line of the service, next to the GP therapy modifier. PT and PTA furnish care together for the entire duration of the service or procedure.
What is a GQ modifier?
Description. HCPCS modifier GQ is used to report services delivered via asynchronous telecommunications system. Guidelines and Instructions. This modifier may be submitted with telehealth services.Jul 16, 2020
What are the new modifiers for 2020?
Beginning in 2020, Medicare is requiring claims to include new modifiers showing when therapy is provided by a PTA or COTA. The PTA modifier is CQ and the COTA modifier is CO. (The GP, GO and KX modifiers will continue to be required.)Aug 7, 2019
What is KF modifier for Medicare?
Modifier KF is a pricing modifier. The HCPCS codes for DME designated as class III devices by the FDA are identified on the DMEPOS fee schedule by presence of the KF modifier.
What is modifier 97 used for?
Modifier 97- Rehabilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97- to the service or procedure code to indicate that the service or procedure ...Nov 20, 2017
How to contact the Health Care Authority?
Providers must check with the Health Care Authority to make sure the client has available units. Providers may contact the Health Care Authority’s Medical Assistance Customer Services Center (MACSC) toll-free at (800) 562-3022 or by Webform or email.
How many digits are in an EPA code?
Enter the appropriate 9-digit EPA code on the billing form in the authorization number field, or in the Authorization or Comments field when billing electronically. EPA codes are designed to eliminate the need for written authorization.
Does Apple Health have managed care?
Apple Health (Medicaid) places clients into an HCA-contracted MCO the same month they are determined eligible for managed care as a new or renewing client. This eliminates a person being placed temporarily in FFS while they are waiting to be enrolled in an MCO or reconnected with a prior MCO. This enrollment policy also applies to clients in FFS who have a change in the program they are eligible for. However, some clients may still start their first month of eligibility in the FFS program because their qualification for MC enrollment is not established until the month following their Medicaid eligibility determination.
Do providers check eligibility?
Providers must check eligibility and know when a client is enrolled and with which MCO. For help with enrolling, clients can refer to the Washington Healthplanfinder’s Get Help Enrolling page.
Does Apple Health pay for MCO?
This means that Apple Health pays a monthly premium to an MCO for providing preventative, primary, specialty, and other health services to Apple Health clients. Clients in managed care must see only providers who are in their MCO’s provider network, unless prior authorized or to treat urgent or emergent care. See HCA’s Apple Health managed care page for further details.
What is a rehabilitation agency?
Rehabilitation Agency - An agency that provides an integrated, multidisciplinary program designed to upgrade the physical functions of handicapped, disabled individuals by bringing together, as a team, specialized rehabilitation personnel.
What is a clinic?
Clinic - A facility established primarily for the provision of outpatient physicians’ services. To meet the definition of a clinic, the facility must meet the following test of physician participation:#N#The medical services of the clinic are provided by a group of three or more physicians practicing medicine together; and#N#A physician is present in the clinic at all times during hours of operation to perform medical services (rather than only administrative services). 1 The medical services of the clinic are provided by a group of three or more physicians practicing medicine together; and 2 A physician is present in the clinic at all times during hours of operation to perform medical services (rather than only administrative services).
What is outpatient rehabilitation?
The agency covers outpatient rehabilitation for the following clients as a short-term benefit to treat an acute medical condition, disease, or deficit resulting from a new injury or post-surgery:
When did Apple Health start a managed care program?
Beginning April 1, 2016, Washington Apple Health (Medicaid) implemented a new managed care enrollment policy placing clients into an agency-contracted MCO the same month they are determined eligible for managed care as a new or renewing client. This policy eliminates a person being placed temporarily in fee-for-service while they are waiting to be enrolled in an MCO or reconnected with a prior MCO.
What is an AI/AN?
Effective July 1, 2017, American Indian/Alaska Native (AI/AN) clients must choose to enroll in one of the managed care plans, either Community Health Plan of Washington (CHPW) or Molina Healthcare of Washington (MHW) under the FIMC model receiving all physical health services, all levels of mental health services and drug and alcohol treatment coordinated by one managed care plan; or they may choose to receive all these services through Apple Health fee-for-service (FFS). If they do not choose, they will be auto-enrolled into Apple Health FFS for all their health care services.
How to contact MACSC?
Providers may contact the agency’s Medical Assistance Customer Services Center (MACSC) toll-free at (800) 562-3022 or by Webform or Email.
What is SW WA?
Clark and Skamania Counties, also known as SW WA region, is the first region in Washington State to implement the FIMC system. This means that physical health services, all levels of mental health services, and drug and alcohol treatment are coordinated through one managed care plan. Neither the RSN nor the BHO will provide behavioral health services in these counties.
How many digits are in an EPA code?
Enter the appropriate 9-digit EPA code on the billing form in the authorization number field, or in the Authorization or Comments field when billing electronically. EPA codes are designed to eliminate the need for written authorization.
Is Apple Health a BHO?
On July 1, 2017, some Apple Health clients were not enrolled in a BHO/FIMC/BHSO program. For these clients, substance use disorder (SUD) services are covered under the fee-for-service (FFS) program.
What is a POC in rehabilitation?
Outpatient rehabilitation therapy services must relate directly and specifically to a written treatment plan (also known as the POC). You must establish the treatment plan/POC before treatment begins, with some exceptions. CMS considers the treatment plan/POC established when it is developed (written or dictated) by a PT, an OT, an SLP, a physician, or an NPP. Only a physician may establish a POC in a Comprehensive Outpatient Rehabilitation Facility (CORF).
How long does a POC last?
The physician’s/NPP’s signature and date on a correctly written POC (with or without an order) satisfies the certification requirement for the duration of the POC or 90 calendar days from the date of the initial treatment, whichever is less. Include the initial evaluation indicating the treatment need in the POC.
How long does a HCPCS code have to be in a day?
CMS requires that when you provide only one 15-minute timed HCPCS code in a day, that you do not bill that service if performed for less than 8 minutes. When providing more than one unit of service, the initial and subsequent service must each total at least 15 minutes, and the last unit may count as a full unit of service if it includes at least 8 minutes of additional services. Do not count all treatment minutes in a day to one HCPCS code if more than 15 minutes of one or more other codes are furnished.
What is CERT contractor?
The Comprehensive Error Rate Testing (CERT) Part A and Part B (A/B) Contractor Task Force is independent from the Centers for Medicare & Medicaid Services (CMS) CERT team and CERT contractors, which are responsible for calculation of the Medicare fee-for-service improper payment rate.
What is a rehab agency?
A rehab agency is a Medicare institutional provider that is subject to not only Medicare Conditions for coverage (CfC), but Conditions of Participation (CoP). A rehab agency at a minimum:
What is PTA in rehab?
Physical therapist assistants (PTA) and occupational therapy assistants (OTA) in a rehab agency are subject to general supervision requirements, which contrasts to direct supervision that is required in a private practice.