Page 173 - Medicare Benefit Policy Manual

• 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.

220.1 - Conditions of Coverage and Payment for Outpatient Physical
Therapy, Occupational Therapy, or Speech-Language Pathology
Services
(Rev. 255, Issued: 01-25-19, Effective: 01- 01- 19, Implementation: 02-26-19)