CMS Pub. 100-04, ch. 5, § 20

A. Uniform Coding

Section 1834(k)(5) of the Act requires that all claims for outpatient rehabilitation therapy

services and all comprehensive outpatient rehabilitation facility (CORF) services be

reported using a uniform coding system. The current Healthcare Common Procedure

Coding System/Current Procedural Terminology is used for the reporting of these

services. The uniform coding requirement in the Act is specific to payment for all CORF

services and outpatient rehabilitation therapy services - including physical therapy,

occupational therapy, and speech-language pathology - that is provided and billed to

Medicare contractors. The Medicare physician fee schedule (MPFS) is used to make

payment for these therapy services at the non facility rate.

Effective for claims submitted on or after April 1, 1998, providers that had not previously

reported HCPCS/CPT for outpatient rehabilitation and CORF services began using

HCPCS to report these services. This requirement does not apply to outpatient

rehabilitation services provided by:

• Critical access hospitals, which are paid on a cost basis, not MPFS;

• RHCs, and FQHCs for which therapy is included in the all-inclusive rate; or

• Providers that do not furnish therapy services.

The following “providers of services” must bill the A/B MAC (A) for outpatient

rehabilitation services using HCPCS codes:

• Hospitals (to outpatients and inpatients who are not in a covered Part A stay);

• Skilled nursing facilities (SNFs) (to residents not in a covered Part A stay and to

nonresidents who receive outpatient rehabilitation services from the SNF);

• Home health agencies (HHAs) (to individuals who are not homebound or

otherwise are not receiving services under a home health plan of care (POC).

• Comprehensive outpatient rehabilitation facilities (CORFs); and

• Providers of outpatient physical therapy and speech-language pathology services

(OPTs), also known as rehabilitation agencies (previously termed outpatient

physical therapy facilities in this instruction).

Note 1. The requirements for hospitals and SNFs apply to inpatient Part B and outpatient

services only. Inpatient Part A services are bundled into the respective prospective

payment system payment; no separate payment is made.

Note 2. For HHAs, HCPCS/CPT coding for outpatient rehabilitation services is required

only when the HHA provides such service to individuals that are not homebound and,

therefore, not under a home health plan of care.

The following practitioners must bill the A/B MAC (B) for outpatient rehabilitation

therapy services using HCPCS/CPT codes:

• Physical therapists in private practice (PTPPs),

• Occupational therapists in private practice (OTPPs),

• Speech-language pathologists in private practice (SLPPs),

• Physicians, including MDs, DOs, podiatrists and optometrists, and

• Certain nonphysician practitioners (NPPs), acting within their State scope of

practice, e.g., nurse practitioners and clinical nurse specialists.

Providers billing to intermediaries shall report:

• The date the therapy plan of care was either established or last reviewed (see

§220.1.3B) in Occurrence Code 17, 29, or 30.

• The first day of treatment in Occurrence Code 35, 44, or 45.

B. Applicable Outpatient Rehabilitation HCPCS Codes

The CMS identifies the codes listed at:

http://www.cms.hhs.gov/TherapyServices/05_Annual_Therapy_Update.asp#TopOfPage

as therapy services, regardless of the presence of a financial limitation. Therapy services

include only physical therapy, occupational therapy and speech-language pathology

services. Therapist means only a physical therapist, occupational therapist or speech-language pathologist. Therapy modifiers are GP for physical therapy, GO for

occupational therapy, and GN for speech-language pathology.

When in effect, any financial limitation will also apply to services represented unless

otherwise noted on the therapy page on the CMS Web site.

C. Additional HCPCS Codes

Some HCPCS/CPT codes that are not on the list of therapy services should not be billed

with a modifier. For example, outpatient non-rehabilitation HCPCS codes G0237,

G0238, and G0239 should be billed without therapy modifiers. These HCPCS codes

describe services for the improvement of respiratory function and may represent either

“incident to” services or respiratory therapy services that may be appropriately billed in

the CORF setting. When the services described by these G-codes are provided by

physical therapists (PTs) or occupational therapists (OTs) treating respiratory conditions,

they are considered therapy services and must meet the other conditions for physical and

occupational therapy. The PT or OT would use the appropriate HCPCS/CPT code(s) in

the 97000 - 97799 series and the corresponding therapy modifier, GP or GO, must be

used.

Another example of codes that are not on the list of therapy services and should not be

billed with a therapy modifier includes the following HCPCS codes: 95860, 95861,

95863, 95864, 95867, 95869, 95870, 95900, 95903, 95904, and 95934. These services

represent diagnostic services - not therapy services; they must be appropriately billed and

shall not include therapy modifiers.

Other codes not on the therapy code list, and not paid under another fee schedule, are

appropriately billed with therapy modifiers when the services are furnished by therapists

or provided under a therapy plan of care and where the services are covered and

appropriately delivered (e.g., the therapist is qualified to provide the service). One

example of non-listed codes where a therapy modifier is indicated regards the provision

of services described in the CPT code series, 29000 through 29590, for the application of

casts and strapping. Some of these codes previously appeared on the therapy code list,

but were deleted because we determined that they represented services that are most often

performed outside a therapy plan of care. However, when these services are provided by

therapists or as an integral part of a therapy plan of care, the CPT code must be

accompanied with the appropriate therapy modifier.

NOTE: The above lists of HCPCS/CPT codes are intended to facilitate the contractor’s

ability to pay claims under the MPFS. It is not intended to be an exhaustive list of

covered services, imply applicability to provider settings, and does not assure coverage of

these services.