CMS Pub. 100-02, ch. 15, § 220

Therapy, Occupational Therapy, and Speech-Language Pathology

Services) Under Medical Insurance

(Rev. 12425; Issued: 12-21-23: Effective: 01-01-24; Implementation: 01-02-24)

A comprehensive knowledge of the policies that apply to therapy services cannot

be obtained through manuals alone. The most definitive policies are Local

Coverage Determinations found at the Medicare Coverage Database

www.cms.hhs.gov/mcd. A list of Medicare contractors is found at the CMS Web

site. Specific questions about all Medicare policies should be addressed to the

contractors through the contact information supplied on their Web sites. General

Medicare questions may be addressed to the Medicare regional offices

http://www.cms.hhs.gov/RegionalOffices/.

A. Definitions

The following defines terms used in this section and §230:

ACTIVE PARTICIPATION of the clinician in treatment means that the

clinician personally furnishes in its entirety at least 1 billable service on at

least 1 day of treatment.

ASSESSMENT is separate from evaluation, and is included in services or

procedures, (it is not separately payable). The term assessment as used in

Medicare manuals related to therapy services is distinguished from language

in Current Procedural Terminology (CPT) codes that specify assessment, e.g.,

97755, Assistive Technology Assessment, which may be payable).

Assessments shall be provided only by clinicians, because assessment requires

professional skill to gather data by observation and patient inquiry and may

include limited objective testing and measurement to make clinical judgments

regarding the patient's condition(s). Assessment determines, e.g., changes in

the patient's status since the last visit/treatment day and whether the planned

procedure or service should be modified. Based on these assessment data, the

professional may make judgments about progress toward goals and/or

determine that a more complete evaluation or re-evaluation (see definitions

below) is indicated. Routine weekly assessments of expected progression in

accordance with the plan are not payable as re-evaluations.

CERTIFICATION is the physician’s/nonphysician practitioner’s (NPP)

approval of the plan of care. Certification requires a dated signature on the

plan of care or some other document that indicates approval of the plan of

care.

The CLINICIAN is a term used in this manual and in Pub 100-04, chapter 5,

section 10 or section 20, to refer to only a physician, nonphysician practitioner

or a therapist (but not to an assistant, aide or any other personnel) providing a

service within their scope of practice and consistent with state and local law.

Clinicians make clinical judgments and are responsible for all services they

are permitted to supervise. Services that require the skills of a therapist, may

be appropriately furnished by clinicians, that is, by or under the supervision of

qualified physicians/NPPs when their scope of practice, state and local laws

allow it and their personal professional training is judged by Medicare

contractors as sufficient to provide to the beneficiary skills equivalent to a

therapist for that service.

COMPLEXITIES are complicating factors that may influence treatment, e.g.,

they may influence the type, frequency, intensity and/or duration of treatment.

Complexities may be represented by diagnoses (ICD codes), by patient factors

such as age, severity, acuity, multiple conditions, and motivation, or by the

patient’s social circumstances such as the support of a significant other or the

availability of transportation to therapy.

A DATE may be in any form (written, stamped or electronic). The date may

be added to the record in any manner and at any time, as long as the dates are

accurate. If they are different, refer to both the date a service was performed

and the date the entry to the record was made. For example, if a physician

certifies a plan and fails to date it, staff may add “Received Date” in writing or

with a stamp. The received date is valid for certification/re-certification

purposes. Also, if the physician faxes the referral, certification, or re-certification and forgets to date it, the date that prints out on the fax is valid.

If services provided on one date are documented on another date, both dates

should be documented.

The EPISODE of Outpatient Therapy – For the purposes of therapy policy, an

outpatient therapy episode is defined as the period of time, in calendar days,

from the first day the patient is under the care of the clinician (e.g., for

evaluation or treatment) for the current condition(s) being treated by one

therapy discipline (PT, or OT, or SLP) until the last date of service for that

discipline in that setting.

During the episode, the beneficiary may be treated for more than one

condition; including conditions with an onset after the episode has begun. For

example, a beneficiary receiving PT for a hip fracture who, after the initial

treatment session, develops low back pain would also be treated under a PT

plan of care for rehabilitation of low back pain. That plan may be modified

from the initial plan, or it may be a separate plan specific to the low back pain,

but treatment for both conditions concurrently would be considered the same

episode of PT treatment. If that same patient developed a swallowing problem

during intubation for the hip surgery, the first day of treatment by the SLP

would be a new episode of SLP care.

EVALUATION is a separately payable comprehensive service provided by a

clinician, as defined above, that requires professional skills to make clinical

judgments about conditions for which services are indicated based on

objective measurements and subjective evaluations of patient performance and

functional abilities. Evaluation is warranted e.g., for a new diagnosis or when

a condition is treated in a new setting. These evaluative judgments are

essential to development of the plan of care, including goals and the selection

of interventions.

FUNCTIONAL REPORTING, which is required on claims for all outpatient

therapy services pursuant to 42CFR410.59, 410.60, and 410.62, uses

nonpayable G-codes and related modifiers to convey information about the

patient’s functional status at specified points during therapy. (See Pub 100-

04, chapter 5, section 10.6) NOTE: Functional reporting requirements are no

longer applicable for claims for dates of service on and after January 1, 2019.

See the NOTE at the beginning of Section 220.4 for more information about

the discontinuation of functional reporting requirements.

RE-EVALUATION provides additional objective information not included in

other documentation. Re-evaluation is separately payable and is periodically

indicated during an episode of care when the professional assessment of a

clinician indicates a significant improvement, or decline, or change in the

patient's condition or functional status that was not anticipated in the plan of

care. Although some state regulations and state practice acts require re-evaluation at specific times, for Medicare payment, reevaluations must also

meet Medicare coverage guidelines. The decision to provide a reevaluation

shall be made by a clinician.

INTERVAL of certified treatment (certification interval) consists of 90

calendar days or less, based on an individual’s needs. A physician/NPP may

certify a plan of care for an interval length that is less than 90 days. There

may be more than one certification interval in an episode of care. The

certification interval is not the same as a Progress Report period.

MAINTENANCE PROGRAM (MP) means a program established by a

therapist that consists of activities and/or mechanisms that will assist a

beneficiary in maximizing or maintaining the progress he or she has made

during therapy or to prevent or slow further deterioration due to a disease or

illness.

NONPHYSICIAN PRACTITIONERS (NPP) means physician assistants,

clinical nurse specialists, and nurse practitioners, who may, if state and local

laws permit it, and when appropriate rules are followed, provide, certify or

supervise therapy services.

PHYSICIAN with respect to outpatient rehabilitation therapy services means a

doctor of medicine, osteopathy (including an osteopathic practitioner),

podiatric medicine, or optometry (for low vision rehabilitation only).

Chiropractors and doctors of dental surgery or dental medicine are not

considered physicians for therapy services and may neither refer patients for

rehabilitation therapy services nor establish therapy plans of care.

PATIENT, client, resident, and beneficiary are terms used interchangeably to

indicate enrolled recipients of Medicare covered services.

PROVIDERS of services are defined in §1861(u) of the Act, 42CFR400.202

and 42CFR485 Subpart H as participating hospitals, critical access hospitals

(CAH), skilled nursing facilities (SNF), comprehensive outpatient

rehabilitation facilities (CORF), home health agencies (HHA), hospices,

participating clinics, rehabilitation agencies or outpatient rehabilitation

facilities (ORF). Providers are also defined as public health agencies with

agreements only to furnish outpatient therapy services, or community mental

health centers with agreements only to furnish partial hospitalization or

intensive outpatient services. To qualify as providers of services, these

providers must meet certain conditions enumerated in the law and enter into

an agreement with the Secretary in which they agree not to charge any

beneficiary for covered services for which the program will pay and to refund

any erroneous collections made. Note that the word PROVIDER in sections

220 and 230 is not used to mean a person who provides a service, but is used

as in the statute to mean a facility or agency such as rehabilitation agency or

home health agency.

QUALIFIED PROFESSIONAL means a physical therapist, occupational

therapist, speech-language pathologist, physician, nurse practitioner, clinical

nurse specialist, or physician’s assistant, who is licensed or certified by the

state to furnish therapy services, and who also may appropriately furnish

therapy services under Medicare policies. Qualified professional may also

include a physical therapist assistant (PTA) or an occupational therapy

assistant (OTA) when furnishing services under the supervision of a qualified

therapist, who is working within the state scope of practice in the state in

which the services are furnished. Assistants are limited in the services they

may furnish (see section 230.1 and 230.2) and may not supervise other

therapy caregivers.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who have been

educated and trained as therapists and qualify to furnish therapy services only

under direct supervision incident to a physician or NPP. See §230.5 of this

chapter. Qualified personnel may or may not be licensed as therapists but

meet all of the requirements for therapists with the exception of licensure.

SIGNATURE means a legible identifier of any type acceptable according to

policies in Pub. 100-08, Medicare Program Integrity Manual, chapter 3,

§3.3.2.4 concerning signatures.

SUPERVISION LEVELS for outpatient rehabilitation therapy services are the

same as those for diagnostic tests defined in 42CFR410.32. Depending on the

setting, the levels include personal supervision (in the room), direct

supervision (in the office suite), and general supervision (physician/NPP is

available but not necessarily on the premises).

SUPPLIERS of therapy services include individual practitioners such as

physicians, NPPs, physical therapists and occupational therapists who have

Medicare provider numbers. Regulatory references on physical therapists in

private practice (PTPPs) and occupational therapists in private practice

(OTPPs) are at 42CFR410.60 (C)(1), 485.701729, and 486.150-163.

THERAPIST refers only to qualified physical therapists, occupational

therapists and speech-language pathologists, as defined in §230.

Qualifications that define therapists are in §§230.1, 230.2, and 230.3. Skills

of a therapist are defined by the scope of practice for therapists in the state).

THERAPY (or outpatient rehabilitation services) includes only outpatient

physical therapy (PT), occupational therapy (OT) and speech-language

pathology (SLP) services paid using the Medicare Physician Fee Schedule or

the same services when provided in hospitals that are exempt from the

hospital Outpatient Prospective Payment System and paid on a reasonable cost

basis, including critical access hospitals.

Therapy services referred to in this chapter are those skilled services furnished

according to the standards and conditions in CMS manuals, (e.g., in this

chapter and in Pub. 100-04, Medicare Claims Processing Manual, chapter 5),

within their scope of practice by qualified professionals or qualified personnel,

as defined in this section, represented by procedures found in the American

Medical Association’s “Current Procedural Terminology (CPT).” A list of

CPT (HCPCS) codes is provided in Pub. 100-04, chapter 5, §20, and in Local

Coverage Determinations developed by contractors.

TREATMENT DAY means a single calendar day on which treatment,

evaluation and/or reevaluation is provided. There could be multiple visits,

treatment sessions/encounters on a treatment day.

VISITS OR TREATMENT SESSIONS begin at the time the patient enters the

treatment area (of a building, office, or clinic) and continue until all services

(e.g., activities, procedures, services) have been completed for that session and

the patient leaves that area to participate in a non-therapy activity. It is likely

that not all minutes in the visits/treatment sessions are billable (e.g., rest

periods). There may be two treatment sessions in a day, for example, in the

morning and afternoon. When there are two visits/ treatment sessions in a

day, plans of care indicate treatment amount of twice a day.

B. References

Paper Manuals. The following manuals, now outdated, were resources for the

Internet Only Manuals:

• Part A Medicare Intermediary Manual, (Pub. 13)

• Part B Medicare Carrier Manual, (Pub. 14)

• Hospital Manual, (Pub. 10)

• Outpatient Physical Therapy/CORF Manual, (Pub. 9)

Regulation and Statute. The information in this section is based in part on the

following current references:

• 42CFR refers to Title 42, Code of Federal Regulation (CFR).

• The Act refers to the Social Security Act.

Internet Only Manuals. Current Policies that concern providers and suppliers

of therapy services are located in many places throughout CMS Manuals.

Sites that may be of interest include:

• Pub.100-01 GENERAL INFORMATION, ELIGIBILITY, AND

ENTITLEMENT

o Chapter 1- General Overview

10.1 - Hospital Insurance (Part A) for Inpatient Hospital, Hospice,

Home Health and SNF Services - A Brief Description

10.2 - Home Health Services

10.3 - Supplementary Medical Insurance (Part B) - A Brief

Description

20.2 - Discrimination Prohibited

• Pub. 100-02, MEDICARE BENEFIT POLICY MANUAL

o Ch 6 - Hospital Services Covered Under Part B

10 - Medical and Other Health Services Furnished to Inpatients of

Participating Hospitals

20 - Outpatient Hospital Services

20.2 - Outpatient Defined

20.4.1 - Diagnostic Services Defined

70 - Outpatient Hospital Psychiatric Services

o Ch 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance

30.4. - Direct Skilled Rehabilitation Services to Patients

40 - Physician Certification and Recertification for Extended Care

Services

50.3 - Physical Therapy, Speech-Language Pathology, and

Occupational

Therapy Furnished by the Skilled Nursing Facility or by Others

Under

Arrangements with the Facility and Under Its Supervision

70.3 - Inpatient Physical Therapy, Occupational Therapy, and

Speech

Pathology Services

o Ch 12 - Comprehensive Outpatient Rehabilitation Facility (CORF)

Coverage

10 - Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided by

Medicare

20 - Required and Optional CORF Services

20.1 - Required Services

20.2 - Optional CORF Services

30 - Rules for Provision of Services

30.1 - Rules for Payment of CORF Services

40 - Specific CORF Services

40.1 - Physicians’ Services

40.2 - Physical Therapy Services

40.3 - Occupational Therapy Services

40.4 – Speech Language Pathology Services

• Pub. 100-03 MEDICARE NATIONAL COVERAGE

DETERMINATIONS MANUAL

o Part 1

20.10 - Cardiac Rehabilitation Programs

30.1 - Biofeedback Therapy

30.1.1 - Biofeedback Therapy for the Treatment of Urinary

Incontinence

50.1 – Speech Generating Devices

50.2 - Electronic Speech Aids

50.4 - Tracheostomy Speaking Valve

o Part 2

150.2 - Osteogenic Stimulator

160.7 - Electrical Nerve Stimulators

160.12 - Neuromuscular Electrical Stimulation (NMES)

160.13 - Supplies Used in the Delivery of Transcutaneous

Electrical Nerve

Stimulation (TENS) and Neuromuscular Electrical Stimulation

(NMES)

160.17 - L-Dopa

o Part 3

170.1 - Institutional and Home Care Patient Education Programs

170.2 - Melodic Intonation Therapy

170.3 - Speech Pathology Services for the Treatment of Dysphagia

180 – Nutrition

o Part 4

230.8 - Non-implantable Pelvic Flood Electrical Stimulator

240.7 - Postural Drainage Procedures and Pulmonary Exercises

270.1 -Electrical Stimulation (ES) and Electromagnetic Therapy

for the

Treatment of Wounds

270.4 - Treatment of Decubitus Ulcers

280.3 - Mobility Assisted Equipment (MAE)

280.4 - Seat Lift

280.13 - Transcutaneous Electrical Nerve Stimulators (TENS)

290.1 - Home Health Visits to A Blind Diabetic

• Pub. 100-08 PROGRAM INTEGRITY MANUAL

o Chapter 3 - Verifying Potential Errors and Taking Corrective

Actions

3.4.1.1 - Linking LCD and NCD ID Numbers to Edits

o Chapter 13 - Local Coverage Determinations

13.5.1 - Reasonable and Necessary Provisions in LCDs

Specific policies may differ by setting. Other policies concerning therapy

services are found in other manuals. When a therapy service policy is specific

to a setting, it takes precedence over these general outpatient policies. For

special rules on:

• CORFs - See chapter 12 of this manual and also Pub. 100-

04, chapter 5;

• SNF - See chapter 8 of this manual and also Pub. 100-04,

chapter 6, for SNF claims/billing;

• HHA - See chapter 7 of this manual, and Pub. 100-04,

chapter 10;

• GROUP THERAPY AND STUDENTS - See Pub. 100-02,

chapter 15, §230;

• ARRANGEMENTS - Pub. 100-01, chapter 5, §10.3;

• COVERAGE is described in the Medicare Program

Integrity Manual, Pub. 100-08, chapter 13, §13.5.1; and

• THERAPY CAPS - See Pub. 100-04, chapter 5, §10.2, for

a complete description of this financial limitation.

C. General

Therapy services are a covered benefit in §§1861(g), 1861(p), and 1861(ll) of

the Act.

Therapy services may also be provided incident to the services of a

physician/NPP under §§1861(s)(2) and 1862(a)(20) of the Act.

Covered therapy services are furnished by providers, by others under

arrangements with and under the supervision of providers, or furnished by

suppliers (e.g., physicians, NPP, enrolled therapists), who meet the

requirements in Medicare manuals for therapy services.

Where a prospective payment system (PPS) applies, therapy services are paid

when services conform to the requirements of that PPS. Reimbursement for

therapy provided to Part A inpatients of hospitals or residents of SNFs in

covered stays is included in the respective PPS rates.

Payment for therapy provided by an HHA under a plan of treatment is

included in the home health PPS rate. Therapy may be billed by an HHA on

bill type 34x if there are no home health services billed under a home health

plan of care at the same time (e.g., the patient is not homebound), and there is

a valid therapy plan of treatment.

In addition to the requirements described in this chapter, the services must be

furnished in accordance with health and safety requirements set forth in

regulations at 42CFR484, and 42CFR485.

When therapy services may be furnished appropriately in a community pool

by a clinician in a physical therapist or occupational therapist private practice,

physician office, outpatient hospital, or outpatient SNF, the practice/office or

provider shall rent or lease the pool, or a specific portion of the pool. The use

of that part of the pool during specified times shall be restricted to the patients

of that practice or provider. The written agreement to rent or lease the pool

shall be available for review on request. When part of the pool is rented or

leased, the agreement shall describe the part of the pool that is used

exclusively by the patients of that practice/office or provider and the times

that exclusive use applies. Other providers, including rehabilitation agencies

(previously referred to as OPTs and ORFs) and CORFs, are subject to the

requirements outlined in the respective State Operations Manual regarding

rented or leased community pools.