GP Physical Therapy service rendered by a Physical Therapist
Medicare Coverage and Payment Conditions:
(Rev. 36, Issued: 06-24-05, Effective: 06-06-05, Implementation: 06-06-05)
• Therapy services are or were required because the individual needed therapy services* (see §220.1.3 - Certification and Recertification of Need for Treatment and Therapy Plans of Care); and
• Plan of care 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 §220.1.2 - Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services)); and
• Therapy services are or were furnished while the individual is or was under the care of a physician* (see §220.1.1 - Outpatient Therapy Must be Under the Care of a Physician/Nonphysician Practitioners (NPP) (Orders/Referrals and Need for Care)); and
• Services must be furnished on an outpatient basis. (See §220.1.4 - Requirement That Services Be Furnished on an Outpatient Basis)
* Physician Orders, Referrals, and Necessity for Care):
An order or physician referral/script is not enough to prove medical necessity and involvement of the physician. A certification for plan of care must be certified by the referring physician. Rember, "reimbursement relies on the certification of the plan of care and not just that of the order". Though the order is important to determine if the patient is under the care of the physician, and the physician must be there to provide certification for the plan of care.
* The plan of care must be established first before treatment begins. The plan of care, must be signed by the professional healthcare provider who established the plan, date it and must be documented with the plan.
Claims containing any of the “always therapy” codes should have one of the therapy modifiers appended (GN, GO, GP). When any code on the list of therapy codes is submitted with specialty codes “65” (physical therapist in private practice), “67” (occupational therapist in private practice), or “15” (speech-language pathologist in private practice) they always represent therapy services, because they are provided by therapists. Carriers or A/B MACs shall return claims for these services when they do not contain therapy modifiers for the applicable HCPCS codes.
The CMS identifies certain codes listed at:
as “sometimes therapy” services, regardless of the presence of a financial limitation. Claims from physicians (all specialty codes) and nonphysician practitioners, including specialty codes “50” (Nurse Practitioner), “89,” (Clinical Nurse Specialist), and “97,” (Physician Assistant) may be processed without therapy modifiers when they are not therapy services. On review of these claims, “sometimes therapy” services that are not accompanied by a therapy modifier must be documented, reasonable and necessary, and payable as physician or nonphysician practitioner services, and not services that the contractor interprets as therapy services.
The CWF will capture the amount and apply it to the limitation whenever a service is billed using the GN, GO, or GP modifier.
For commercial career, contact respective career for payor policies.