CMS Pub. 100-02, ch. 12, § 30.1

The payment basis for CORF services is 80 percent of the lesser of: (1) the actual charge

for the service or (2) the physician fee schedule amount for the service when the

physician fee schedule establishes a payment amount for such service. Payment for

CORF services under the physician fee schedule is made for physical therapy,

occupational therapy, speech-language pathology and respiratory therapy services, as

well as the nursing and social and/or psychological services, which are a part of, or

directly relate to, the rehabilitation plan of treatment.

Payment for covered durable medical equipment, orthotic and prosthetic (DMEPOS)

devices and supplies provided by a CORF is based upon: the lesser of 80 percent of

actual charges or the payment amount established under the DMEPOS fee schedule; or,

the single payment amount established under the DMEPOS competitive bidding program,

provided that payment for such an item is not included in the payment amount for other

CORF services.

If there is no fee schedule amount for a covered CORF item or service, payment should

be based on the lesser of 80 percent of the actual charge for the service provided or an

amount determined by the local Medicare contractor.

The following conditions apply to CORF physical therapy, occupational therapy, and

speech-language pathology services;

• Claims must contain the required functional reporting. (Reference: Sections 42

CFR 410.105.) Refer to Pub. 100-04, Medicare Claims Processing Manual,

chapter 5, section 10.6. NOTE: Functional reporting and documentation

requirements are no longer applicable for claims for dates of service on and after

January 1, 2019. For more information, refer to subsection F in section 30

above.

• The functional reporting on claims must be consistent with the functional

limitations identified as part of the patient’s therapy plan of care and expressed as

part of the patient’s therapy goals; effective for claims with dates of service on

and after January, 1, 2013. (Reference: 42 CFR 410.105.) See Pub. 100-04,

Medicare Claims Processing Manual, chapter 5, section 10.6. NOTE: Functional

reporting and documentation requirements are no longer applicable for claims

for dates of service on and after January 1, 2019. For more information, refer to

subsection F in section 30 above.

• The National Provider Identifier (NPI) of the certifying physician identified for a

CORF physical therapy, occupational therapy, and speech-language pathology

plan of treatment must be included on the therapy claim. This requirement is

effective for claims with dates of service on or after October 1, 2012. (See Pub.

100-04, Medicare Claims Processing Manual, chapter 5, section 10.3.)

Payment for CORF social and/or psychological services is made under the physician fee

schedule only for HCPCS code G0409, as appropriate, and only when billed using

revenue codes 0560, 0569, 0910, 0911, 0914 and 0919.

Payment for CORF respiratory therapy services is made under the physician fee schedule

when provided by a respiratory therapist as defined at 42CFR485.70(j) and, only to the

extent that these services support or are an adjunct to the rehabilitation plan of treatment,

when billed using revenue codes 0410, 0412 and 0419. Separate payment is not made for

diagnostic tests or for services related to physiologic monitoring services which are

bundled into other respiratory therapy services appropriately performed by a respiratory

therapist, such as HCPCS codes G0237, G0238 and G0239.

Payment for CORF nursing services is made under the physician fee schedule only when

provided by a registered nurse as defined at 42CFR485.70(h) for nursing services only to

the extent that these services support or are an adjunct to the rehabilitation plan of

treatment. In addition, payment for CORF nursing services is made only when provided

by a registered nurse. HCPCS code G0128 is used to bill for these services and only with

revenue codes 0550 and 0559.

For specific payment requirements for CORF items and services see Pub. 100-04,

Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and

CORF/OPT Services.