Page 174 - Medicare Benefit Policy Manual

Reference: 42CFR424.24

Refer to §230.4 for physical therapist/occupational therapist in private practice rules.

Coverage rules for specific services are in Pub. 100-03, Medicare National Coverage
Determinations Manual.

Other payment rules are found in Pub. 100-04, Medicare Claims Processing Manual,
chapter 5.

Since the outpatient therapy benefit under Part B provides coverage only of therapy
services, payment can be made only for those services that constitute therapy. In cases
where there is doubt about whether a service is therapy, the contractor’s local coverage
determination (LCD) shall prevail.

In order for a service to be covered, it must have a benefit category in the statute, it must
not be excluded and it must be reasonable and necessary. Therapy services are a benefit
under §1861 of the Act. Consult Pub. 100-08, chapter 13, §13.5.1 for full descriptions of
a reasonable and necessary service.

Outpatient therapy services furnished to a beneficiary by a provider or supplier are
payable only when furnished in accordance with certain conditions. The following
conditions apply.

• Services are or were required because the individual needed therapy services (see
42CFR424.24(c),§220.1.3);

• A plan for furnishing such services has been established by a physician/NPP or by
the therapist providing such services and is periodically reviewed by a
physician/NPP* (see 42CFR424.24(c), §220.1.2);

• Services are or were furnished while the individual is or was under the care of a
physician* (see 42CFR424.24(c), §220.1.1);

• In certifying an outpatient plan of care for therapy a physician/NPP is
certifying that the above three conditions are met (42 CFR 424.24(c)).
Certification is required for coverage and payment of a therapy claim.

• Claims submitted for outpatient (and CORF) PT, OT, and SLP services must
contain the National Provider (NPI) of the certifying physician identified for a PT,
OT, and SLP plan of care. This requirement is effective for claims with dates of
service on or after October 1, 2012. (See Pub. 100-04, Medicare Claims
Processing Manual, chapter 5, section 10.3.)