Part B Outpatient Rehabilitation and Comprehensive Outpatient

10 - Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services - General (Rev. 3454, Issued: 02-04-16, Effective: 07-01-16, Implementation: 07-05-16) Language in this section is defined or described in Pub. 100-02, chapter 15, sections 220 and 230. Section §1834(k)(5) to the Social Security Act (the Act), requires that all claims for outpatient rehabilitation services and comprehensive outpatient rehabilitation facility (CORF) services, be reported using a uniform coding system. The CMS chose HCPCS (Healthcare Common Procedure Coding System) as the coding system to be used for the reporting of these services. This coding requirement is effective for all claims for outpatient rehabilitation services and CORF services submitted on or after April 1, 1998. The Act also requires payment under a prospective payment system for outpatient rehabilitation services including CORF services. Effective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for outpatient therapy services furnished by: • Comprehensive outpatient rehabilitation facilities (CORFs); • Outpatient physical therapy providers (OPTs), also known as rehabilitation agencies; • 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); and • Home health agencies (HHAs) (to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC)). NOTE: No provider or supplier other than the SNF will be paid for therapy services during the time the beneficiary is in a covered SNF Part A stay. For information regarding SNF consolidated billing see chapter 6, section 10 of this manual. Similarly, under the HH prospective payment system, HHAs are responsible to provide, either directly or under arrangements, all outpatient rehabilitation therapy services to beneficiaries receiving services under a home health POC. No other provider or supplier will be paid for these services during the time the beneficiary is in a covered Part A stay. For information regarding HH consolidated billing see chapter10, section 20 of this manual. Section 143 of the Medicare Improvements for Patients and Provider’s Act of 2008 (MIPPA) authorizes the Centers for Medicare & Medicaid Services (CMS) to enroll speech-language pathologists (SLP) as suppliers of Medicare services and for SLPs to begin billing Medicare for outpatient speech-language pathology services furnished in private practice beginning July 1, 2009. Enrollment will allow SLPs in private practice to bill Medicare and receive direct payment for their services. Previously, the Medicare program could only pay SLP services if an institution, physician or nonphysician practitioner billed them. In Chapter 23, as part of the CY 2009 Medicare Physician Fee Schedule Database, the descriptor for PC/TC indicator “7”, as applied to certain HCPCS/CPT codes, is described as specific to the services of privately practicing therapists. Payment may not be made if the service is provided to either a hospital outpatient or a hospital inpatient by a physical therapist, occupational therapist, or speech-language pathologist in private practice. The MPFS is used as a method of payment for outpatient rehabilitation services furnished under arrangement with any of these providers. In addition, the MPFS is used as the payment system for CORF services identified by the HCPCS codes in §20. Assignment is mandatory. Services that are paid subject to the MPFS are adjusted based on the applicable payment locality. Rehabilitation agencies and CORFs with service locations in different payment localities shall follow the instructions for multiple service locations in chapter 1, section 170.1.1. The Medicare allowed charge for the services is the lower of the actual charge or the MPFS amount. The Medicare payment for the services is 80 percent of the allowed charge after the Part B deductible is met. Coinsurance is made at 20 percent of the lower of the actual charge or the MPFS amount. The general coinsurance rule (20 percent of the actual charges) does not apply when making payment under the MPFS. This is a final payment. The MPFS does not apply to outpatient rehabilitation services furnished by critical access hospitals (CAHs) or hospitals in Maryland. CAHs are to be paid on a reasonable cost basis. Maryland hospitals are paid under the Maryland All-Payer Model. Contractors process outpatient rehabilitation claims from hospitals, including CAHs, SNFs, HHAs, CORFs, outpatient rehabilitation agencies, and outpatient physical therapy providers for which they have received a tie in notice from the Regional Office (RO). These provider types submit their claims to the contractors using the ASC X12 837 institutional claim format or the CMS-1450 paper form when permissible. Contractors also process claims from physicians, certain nonphysician practitioners (NPPs), therapists in private practices (TPPs), (which are limited to physical and occupational therapists, and speech-language pathologists in private practices), and physician-directed clinics that bill for services furnished incident to a physician’s service (see Pub. 100-02, Medicare Benefit Policy Manual, chapter 15, for a definition of “incident to”). These provider types submit their claims to the contractor using the ASC X 12 837 professional claim format or the CMS-1500 paper form when permissible. There are different fee rates for nonfacility and facility services. Chapter 23 describes the differences in these two rates. (See fields 28 and 29 of the record therein described). Facility rates apply to professional services performed in a facility other than the professional’s office. Nonfacility rates apply when the service is performed in the professional’s office. The nonfacility rate (that is paid when the provider performs the services in its own facility) accommodates overhead and indirect expenses the provider incurs by operating its own facility. Thus it is somewhat higher than the facility rate. Contractors pay the nonfacility rate on institutional claims for services performed in the provider’s facility. Contractors may pay professional claims using the facility or nonfacility rate depending upon where the service is performed (place of service on the claim), and the provider specialty. Contractors pay the codes in §20 under the MPFS on professional claims regardless of whether they may be considered rehabilitation services. However, contractors must use this list for institutional claims to determine whether to pay under outpatient rehabilitation rules or whether payment rules for other types of service may apply, e.g., OPPS for hospitals, reasonable costs for CAHs. Note that because a service is considered an outpatient rehabilitation service does not automatically imply payment for that service. Additional criteria, including coverage, plan of care and physician certification must also be met. These criteria are described in Pub. 100-02, Medicare Benefit Policy Manual, chapters 1 and 15. Payment for rehabilitation services provided to Part A inpatients of hospitals or SNFs is included in the respective PPS rate. Also, for SNFs (but not hospitals), if the beneficiary has Part B, but not Part A coverage (e.g., Part A benefits are exhausted), the SNF must bill for any rehabilitation service. Payment for rehabilitation therapy services provided by home health agencies under a home health plan of care is included in the home health PPS rate. HHAs may submit bill type 34X and be paid under the MPFS if there are no home health services billed under a home health plan of care at the same time, and there is a valid rehabilitation POC (e.g., the patient is not homebound). An institutional employer (other than a SNF) of the TPPs, or physician performing outpatient services, (e.g., hospital, CORF, etc.), or a clinic billing on behalf of the physician or therapist may bill the contractor on a professional claim. The MPFS is the basis of payment for outpatient rehabilitation services furnished by TPPs, physicians, and certain nonphysician practitioners or for diagnostic tests provided incident to the services of such physicians or nonphysician practitioners. (See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 15, for a definition of “incident to, therapist, therapy and related instructions.") Such services are billed to the contractor on the professional claim format. Assignment is mandatory. The following table identifies the provider and supplier types, and identifies which claim format they may use to submit claims for outpatient therapy services to the contractor. “Provider/Supplier Service” Type Format Bill Type Comment Inpatient SNF Part A Institutional 21X Included in PPS Inpatient hospital Part B Institutional 12X Hospital may obtain services under arrangements and bill, or rendering provider may bill. Inpatient SNF Part B (audiology tests are not included) Institutional 22X SNF must provide and bill, or obtain under arrangements and bill. Outpatient hospital Institutional 13X Hospital may provide and bill or obtain under arrangements and bill. Outpatient SNF Institutional 23X SNF must provide and bill or obtain under arrangements and bill. HHA billing for services not rendered under a Part A or Part B home health plan of care, but rendered under a therapy plan of care. Institutional 34X Service not under home health plan of care. Outpatient physical therapy providers (OPTs), also known as rehabilitation agencies Institutional 74X Paid MPFS for outpatient rehabilitation services. Comprehensive Outpatient Rehabilitation Facility (CORF) Institutional 75X Paid MPFS for outpatient rehabilitation services and all other services except drugs. Drugs are paid 95% of the AWP. Physician, NPPs, TPPs, (therapy services in hospital or SNF) Professional See Chapter 26 for place of service coding. Payment may not be made for therapy services to Part A inpatients of hospitals or SNFs, or for Part B SNF residents. NOTE: Payment may be made to physicians and NPPs for their professional services defined as “sometimes therapy” (not part of a therapy plan) in certain situations; for example, when furnished to a beneficiary “Provider/Supplier Service” Type Format Bill Type Comment registered as an outpatient of a hospital. Physician/NPP/TPPs office, or patient’s home Professional See Chapter 26 for place of service coding. Paid via MPFS. Critical Access Hospital - inpatient Part B Institutional 12X Rehabilitation services are paid at cost. Critical Access Hospital – outpatient Part B Institutional 85X Rehabilitation services are paid at cost. For a list of the outpatient rehabilitation HCPCS codes see §20. If a contractor receives an institutional claim for one of these HCPCS codes with dates of service on or after July 1, 2003, that does not appear on the supplemental file it currently uses to pay the therapy claims, it contacts its professional claims area to obtain the non- facility price in order to pay the claim. NOTE: The list of codes in §20 contains commonly utilized codes for outpatient rehabilitation services. Contractors may consider other codes on institutional claims for payment under the MPFS as outpatient rehabilitation services to the extent that such codes are determined to be medically reasonable and necessary and could be performed within the scope of practice of the therapist providing the service.