LCD ID Number: L35036 Status: A-Approved
LCD Title: Therapy and Rehabilitation Services (PT, OT)
Geographic Jurisdiction: New Jersey Other Jurisdictions
Original Determination Effective Date:
Original Determination Ending Date:
Revision Effective Date:
Revision End Date:
CMS National Coverage Policy:
This LCD supplements but does not replace, modify, or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for therapy and rehabilitation services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify, or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for therapy and rehabilitation services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:
- CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
- Chapter 8, Section 30.2 Skilled Nursing and Skilled Rehabilitation Services and Section 30.4.1 Skilled Physical Therapy
- Chapter 12, Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage
- Chapter 15, Section 220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
- CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual,
- Chapter 1, Part 2, Section 150.5 Diathermy Treatment, Section 150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders, Section 160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation, Section 160.12 Neuromuscular Electrical Stimulator (NMES), Section 160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy), Section 160.16 Vertebral Axial Decompression (VAX-D) and Part 4, Section 230.8 Non-Implantable Pelvic Floor Electrical Stimulator, Section 250.1 Treatment of Psoriasis, Section 270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds, and Section 270.6 Infrared Therapy Devices
- CMS IOM Publication 100-04, Medicare Claims Processing Manual,
- Chapter 5, Section 10 Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services – General and Section 20 HCPCS Coding Requirement
- CMS IOM Publication 100-08, Medicare Program Integrity Manual,
- Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD
Social Security Act (Title XVIII) Standard References:
- Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
- Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment may be made for items or services which are not medically reasonable and necessary for the diagnosis or treatment of illness or injury.
- Title XVIII of the Social Security Act, Section 1862(a)(6) states that no payment shall be made for personal comfort items.
- Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes screening and routine physical checkups.
Federal Register References:
- 42 CFR, Section 409.32 Criteria for skilled services and the need for skilled services.
- 42 CFR, Section 484.4 Personnel qualifications.
- 42 CFR, Section 485.713 Condition of participation: Physical therapy services.
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02/08/2023 07:19:46 126.96.36.199