Rehabilitation Therapies

Coverage

Rehabilitation therapy procedure codes are daily, per visit codes, with the exception of respiratory therapy, which may be provided more than once per day.

Eligible Members

1. To receive payment for rehabilitation therapy, the services must be all of the following:
   1. Provided in the member’s home
   2. Ordered by a physician
   3. Appropriate to meet the member’s needs
   4. Specified in the plan of care
   5. Medically necessary
2. Provided to the member whose functional status is expected to progress toward or achieve the goals specified in the member’s plan of care within a 60-day period or less time depending on the member’s individual condition (if the service is a Medicare-covered service and is provided to a member who is eligible for Medicare, the plan of care must be reviewed at the intervals required by Medicare).
3. Rehabilitation services cannot be covered when the member can reasonably access these services outside his/her residence, excluding the assessment, counseling, and education. A member who leaves the home at will, or a parent who could easily transport the child, must obtain these services at the rehabilitation center and will not be eligible for home care therapies.

Authorization Requirements

Effective November 2, 2023, authorization is not required for rehabilitation therapy. Providers must document the following in the member’s record and provide this information to PrimeWest Health if requested:

1. All evaluations
2. Services provided including:
   1. Date, type, and length of each service provided
   2. The name and title of the person(s) providing each service
3. A statement every 30 days by the therapist indicating the nature, scope, duration, and intensity of the therapy are appropriate to the medical condition
4. Client progress and goals
5. Discharge plans

Eligible Providers

Therapists must be employed by a Medicare-certified home health agency enrolled with PrimeWest Health. Services may be provided by the following:

1. Licensed Physical Therapist (PT)
2. Registered Occupational Therapist (OT)
3. Certified Occupational Therapy Assistant (COTA)^*
4. Physical Therapy Assistant (PTA)*
5. Respiratory Therapist (RT)
6. Speech Therapist (ST)

^*When services are provided by an assistant and the licensed or registered therapist is not on the premises (the member’s home), the services are billed with a TF modifier, and the payment will be at 65 percent of the therapist’s rate. The licensed PT or registered OT must provide in-person direction to the assistant at least every sixth visit. When a home visit is made jointly by the therapist and assistant, the provider may bill only for the therapist’s visit. Providers may not bill for both the PT and PTA (or the OT and COTA) when a joint home visit is made.

Covered Services

Rehabilitation therapy services are daily, per visit codes, with the exception of respiratory therapy, which may be provided more than once per day for services provided in the member’s home. All therapies must be specified in the member’s plan of care.

The following home care therapy services are not subject to the outpatient rehabilitative service thresholds:

If the service is a Medicare-covered service and is provided to a member who is eligible for Medicare, the plan of care must be reviewed at the intervals required by Medicare.

Therapy Classifications

Therapies must be classified as to whether they are restorative or specialized maintenance.

Restorative therapy is a health service that is:

1. Specified in the member’s plan of care;
2. Ordered by a physician; and
3. Designed to restore the member’s functional status to a level consistent with the member’s physical or mental limitations.

Maintenance therapy is a health service that:

1. Is specified in the member’s plan of care;
2. Is ordered by a physician;
3. Is necessary for maintaining a member’s functional status at a level consistent with the member’s physical or mental limitations; and
4. May include treatments in addition to rehabilitative nursing services.
5. Requires supervision by a qualified therapist
6. Requires reassessment every 30 days by a qualified therapist

Non-Covered Services

1. Rehabilitation services in the home when the member can reasonably access these services outside his/her residence, or to a member who can leave at will
2. Rehabilitation provided to a child who could easily be transported by a parent/guardian to a rehabilitation center
3. Therapies provided in other settings, such as a clinic or day program, or as an inpatient

Billing

1. When services are provided by an assistant and the licensed or registered therapist is not on the premises, the services are billed with a modifier, and the payment will be at 65 percent of the therapist’s rate. The licensed PT or registered OT must provide in-person direction to the assistant at least every sixth visit.
2. When a home visit is made jointly by the therapist and assistant, the provider may bill only for the therapist’s visit. Providers may not bill for both the PT and PTA (or the OT and COTA) when a joint home visit is made.
3. When billing for specialized maintenance therapies, use a modifier on the claim to differentiate services.

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Updates_11/30/2023