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Contractor Information

Contractor Name: National Government Services, Inc. - Full list of policies of this Medicare Contractor Contractor Number: 14512 Contractor Type: MAC B

LCD Information

LCD ID Number: L33631 Status: A-Approved LCD Title: Outpatient Physical and Occupational Therapy Services Geographic Jurisdiction: Vermont Other Jurisdictions Original Determination Effective Date: 10/01/2015 Original Determination Ending Date: Revision Effective Date: 01/01/2020 Revision End Date: CMS National Coverage Policy: Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act. Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources: Title XVIII of the Social Security Act (SSA): Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim. Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners. Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Section 1862(a)(20) excludes payment for PT or OT services furnished incident to the physician by personnel that do not meet the qualifications that apply to therapists, except licensing. Code of Federal Regulations 42 CFR, Sections 410.59 and 410.61 describe outpatient occupational therapy services and the plan of treatment for outpatient rehabilitation services, respectively. 42 CFR, Sections 410.60 and 410.61 describe outpatient physical therapy services and the plan of treatment for outpatient rehabilitation services, respectively. 42 CFR, Sections 410.74, 410.75, 410.76, and 419.22 define the services of non-physician practitioners. 42 CFR, Sections 424.24 and 424.27 describe therapy certification and plan requirements. 42 CFR, Sections 424.4, 482.56, 484 and 485.705 define therapy personnel qualification requirements. 42 CFR, Section 486 describes coverage for services rendered by physical therapists in independent practice. Federal Register Federal Register, Vol. 72, No. 227, November 27, 2007, pages 66328-66333 and 66397-66408, and the correction notice for this rule, published in the Federal Register on January 15, 2008, pages 2431-2433, addresses personnel qualification standards for therapy services and certification requirements. Federal Register, July 22, 2002, Decision Memo for Neuromuscular Electrical Stimulation (NMES) for Spinal Cord Injury (CAG 00153R), at: http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=55& CMS Publications: CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: 220 through 230 Coverage and documentation requirements for physical and occupational therapy services. CMS Publication 100-03, Medicare National Coverage Decisions (NCD) Manual, (multiple sections): provides coverage information on several specific types of therapy services. See body of LCD for individual references. CMS Publication 100-04, Claims Processing Manual, Chapter 5: 10.2 Financial limitation for therapy services (therapy cap). CMS Publication 100-04, Claims Processing Manual, Chapter 5: 20-100 HCPCS coding and therapy billing requirements. CMS Publication 100-04, Claims Processing Manual, Chapter 20: 1-10 Orthotics billing. CMS, “11 Part B Billing Scenarios for PTs and OTs”, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp#TopOfPage Communication from CMS that the Contractor LCD is not required to include the V57.1-V57.89 ICD-9-CM codes. CMS Transmittal No. 4149, Publication 100-04, Medicare Claims Processing Manual, October 23, 2018, removes Functional Reporting requirements and edits for outpatient therapy services. CMS Transmittal No. 179, Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius, Change request #8458, January 14, 2014, provides clarification that coverage of skilled nursing and skilled therapy services “…does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.” Sorry, you need to login or register to view additional sections of this Medicare policy. *