Description
Documentation will be reviewed to determine if therapy meets Medicare coverage criteria, meets applicable coding guidelines, and/or is medically reasonable and necessary. Appropriate use of modifier KX will be evaluated. Use of modifier KX indicates that the clinician attests that services at, and above, the therapy threshold are medically necessary and reasonable, with justification for continued therapy documented in the patient’s medical record.
Affected Code(s)
Physical Therapy
97012, 97035, 97110, 97112, 97116, 97124, 97140, 97150, 97530, 97535, 97161, 97162, 97163, 97164
Occupational Therapy
29200, 29240, 29260, 29280, 29520, 29530, 29540, 29550, 29799, 90901, , 97014, 97032, 97110, 97112, 97165, 97166, 97167, 97168, 97530, 97535, 97542, 97750, 97760, 97761, G0281, G0282, G0283
Speech Therapy
92507, 92520, 92521, 92522, 92523, 92524, 92526, 92606, 92609, 92610, 92630, 92633, 96125, 97129, 97130
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1833(e)- Payment of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled 1835(a)(2)- Procedure for Payment of Claims of Providers of Services
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1861(g)- Outpatient Occupational Therapy Services
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1861(p)- Outpatient Physical Therapy Services
5. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1861(ll)- Speech-Language Pathology Services; Audiology Services
6. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, 1862(a)(1)(A)-Exclusions from Coverage and Medicare as a Secondary Payer
7. 42 Code of Federal Regulations (CFR) §405.929- Post-Payment Review
8. 42 Code of Federal Regulations (CFR) §405.930- Failure to Respond to Additional Documentation Request
9. 42 Code of Federal Regulations (CFR) §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
10. 42 Code of Federal Regulations (CFR) §405.986- Good Cause for Reopening
11. 42 Code of Federal Regulations 42 CFR §409.44 (c)(2)- Physical therapy, speech-language pathology services, and occupational therapy
12. 42 Code of Federal Regulations (CFR) §410.105 Requirements for coverage of CORF services
13. 42 Code of Federal Regulations (CFR) §410.59 Outpatient occupational therapy services: Conditions
14. 42 Code of Federal Regulations (CFR) §410.60 Outpatient physical therapy services: Conditions
15. 42 Code of Federal Regulations (CFR) §410.61 Plan of treatment requirements for outpatient rehabilitation services
16. 42 Code of Federal Regulations (CFR) §424.10 Purpose and scope
17. 42 Code of Federal Regulations (CFR) §424.11 General procedures
18. 42 Code of Federal Regulations (CFR) §424.24 Requirements for medical and other health services furnished by providers under Medicare Part B
19. Medicare Benefit Policy Manual Chapter 15 §220 - Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, or Speech-Language Pathology Service) Under Medical Insurance
20. Medicare Benefit Policy Manual Chapter 15 §230- Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
21. Medicare Claims Processing Manual, Chapter 5 §10- Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services- General
22. Medicare Claims Processing Manual (MCPM), Chapter 5 §20.2 – Reporting of Service Units with HCPCS
23. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
24. American Medical Association Current Procedural Terminology Codebook
25. HCPCS Level II Codebook