Outpatient

PHYSICAL, SPEECH, AND OCCUPATIONAL THERAPY GUIDELINES. (1) Reimbursement for all physical, speech, and occupational therapy services shall not exceed the lesser of billed charges or the fees listed in the rate tables (based on 180% of Medicare), no matter where the services are performed, except home health services. (2) There shall be no reimbursement for either hot packs or cold packs provided to an employee who has suffered a compensable work-related injury under the Workers’ Compensation Law. (3) For physical therapy, occupational therapy, or speech therapy, there shall be no fee allowable for any modalities or therapeutic procedures performed in excess of four (4) units of modalities, therapeutic procedures, or combination thereof per type of therapy per day per employee. The definitions of modality and therapeutic procedures from the most recent American Medical Association’s Current Procedural Terminology (CPT®) edition are applicable. When determining the correct number of units for billing or reimbursement for time-based therapy codes, minutes of service specified in the code description shall be rounded to the nearest unit. For example, for codes with 15 minutes of time in the description, a unit shall be billed after 8 minutes of therapy. If the sum of two services is 8 minutes or more, the service provided for the greater amount of time is to be reimbursed as follows: (a) 1 unit is greater than or equal to 8 minutes and less than or equal to 22 minutes. (b) 2 units is greater than or equal to 23 minutes and less than or equal to 37 minutes. (c) 3 units is greater than or equal to 38 minutes and less than or equal to 52 minutes. (d) 4 units is greater than or equal to 53 minutes and less than or equal to 67 minutes. (4) For Functional Capacity Evaluations, the four-unit (time measurement) maximum may not apply if the documentation supports the extra units. Use CPT® code 97750, physical performance test or measurement, with written report, each 15 minutes, to bill for Functional Capacity Evaluations. (5) For Work Hardening/Conditioning Programs use the CPT® code 97545, work hardening/conditioning; initial 2 hours and CPT® code 97546, work hardening/conditioning. Each additional hour shall be billed for a maximum of 6 hours per day or 60 hour maximum and are subject to utilization review prior approval. (6) Whenever physical therapy, occupational therapy, or speech therapy services exceed twelve (12) visits, such treatment may be reviewed pursuant to the employer’s utilization review program in accordance with the procedures set forth in Chapter 0800-02-06 of the Bureau’s Utilization Review rules before further physical therapy and/or occupational therapy services may be certified for payment by the employer. Such certification shall be completed within the timeframes set forth in Chapter 0800-02-06 to assure no interruption occurs in the delivery of necessary services. Failure by a provider to properly certify such services as prescribed herein may result in the forfeiture of any payment for uncertified services.