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A new physical therapist that joins the Preferred Physical Therapy (PT) Network will be on a provisional status for two years in order to determine continued participation. The provider's National Provider Identifier (NPI) should be used when filing claims. Benefits for services for physical therapy are determined based on the member's contract benefit.
For physical therapy to be medically necessary, it must be reasonable and necessary for the patient’s diagnosis or treatment of the patient’s condition. Medical necessity is indicated when:
Services such as the application of hot and cold packs, use of exercise equipment, and repetitive exercises do not ordinarily require the skills and full attention of a qualified physical therapist; therefore, they are not separately billable. If such treatments are given as a prerequisite to a skilled physical therapy procedure, they are considered part of that modality and are not separately billable.
Preferred PTs are responsible for notifying the patient of services that are not medically necessary for treatment of his/her condition. The Notification of Non-Covered Services form is an example of a non-covered statement that can be used. The patient should sign the statement before the services are rendered. Be sure to keep the signed copy in the patient’s medical record.
Examples of Non-Covered Services:
Remember: Blue Cross and Blue Shield of Alabama does not provide benefits for professional services of a physical therapist rendered to a member who is related to the physical therapist by blood or marriage or who lives in the provider’s household.
Non-Covered Providers of Physical Therapy Services
Athletic trainers, exercise physiologists, massage therapist, RNs, LPNs, certified strength trainers, physical therapy aides, secretaries, and office personnel are not considered covered providers. Services performed by these providers are not covered. For non-grandfathered plans, services provided by any provider acting within the scope of his/her license or certification will be covered.
Filing for these kinds of services, as well as occupational and speech therapy services, under the Preferred PT's NPI is not acceptable and is not reimbursable.
Precertification requirements are determined first by the member's benefits. Second, if there are no benefit requirements for precertification or benefit limits, Preferred PT Network requirements apply.
Preferred PTs must submit precertification for physical therapy services rendered to a new patient beginning with the 16th visit. This process should be initiated prior to the 14th visit. If precertification is not obtained, all services associated with the 16th visit and subsequent visits will be non-covered and the patient will be held harmless. Patients may be billed if they have signed a non-covered services statement for each visit. The statement must indicate that the patient has been properly informed that the services to be rendered are not covered by Blue Cross and Blue Shield of Alabama and that the patient will be responsible for paying for the services. There are no retroactive certifications for these contracts. When filing a request for precertification, complete the appropriate Physical Therapy Precertification Form and submit it to:
Blue Cross and Blue Shield of Alabama
Fax Number: 205-220-0941
Attention: Physical Therapy Precertification
If all requested information is not received, a determination will not be made. Determinations will be made within one business day of receipt of all information. Precertification requests received after 2:00 p.m. will be considered as received the following business day. Notification of the determination will be made by letter or by facsimile.
Note: Blue Advantage® has a separate precertification form for therapy.
Precertification is not required for:
Listed below are a few of the Current Procedural Terminology (CPT) codes covered under the PT Network. Special care should be given in reporting and documenting these services.
Physical therapy evaluation
|97002||Physical therapy re-evaluation
Re-evaluation is considered medically necessary when there is: an unanticipated change in patient status; a failure to respond to therapy interventions as expected; the need for a new care plan; additional injury; or an additional surgery. This code is not appropriate for general status updates to physicians.
|97010||Application of a modality to 1 or more areas; hot or cold packs
Application of hot or cold packs does not ordinarily require the skills, expertise, and full attention of a qualified therapist and are not separately billable.
|97110||Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercise to develop strength & endurance, range of motion & flexibility
Documentation should indicate specific procedures, duration of time and response to treatment. Blue Cross only considers procedures medically necessary if a skilled licensed individual is needed to provide the service.
|97112||Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities|
Therapeutic procedure, 1 or more areas, each 15 minutes, aquatic therapy with therapeutic exercises
|97116||Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)|
|97124||Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
In order to be considered for coverage when billing therapeutic massage, the massage must be performed by a licensed physical therapist. Massage therapists, exercise physiologists, physician assistants, and office personnel are not considered as providers eligible for coverage.
Therapeutic massage must be of a skilled nature and must be part of a specific,
diagnosis-related goal. The services must be of a level of complexity and sophistication that they require the skills and expertise of a physician or physical therapist. Massages performed with hand-held devices such as vibrators are not considered skilled in nature and are not reimbursable.
|97140||Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
(Do not report 97140 in conjunction with 29581-29584)
Treatment must be diagnosis-related and documentation must support proper billing of CPT code 97140 and contain the following:
Therapeutic activities, direct (one to one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
|97597||Debridement (e.g., high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (eg, fibrin devitalized epidermisand/or dermis, exudate, debris, biofilm) including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session; total wound(s) surface area; first 20 sq cm or less|
|97598||Each additional 20 sq cm, or part thereof (List separately in addition to code for primary procedure)|
|97605||Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters|
|97606||Negative pressure wound therapy (eg, vacuum assisted drainage collection), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters|
Physical performance test or measurements (eg, musculoskeletal, functional capacity), with written report, each 15 minutes
Blue Cross and Blue Shield of Alabama covers the initial two services of isokinetic testing for a comparison of the involved and uninvolved extremity. Follow-up testing may be billed monthly, if medically necessary. Only one service may be billed at the follow-up testing. Billing a service of each motion of a joint is not reimbursable. Billing for this code should include torque curves and other graphic reports with interpretation.
Therapeutic massage must be of a skilled nature and must be part of a specific, diagnosis related goal. The services must be of a level of complexity and sophistication that they require the skills and expertise of a physician or physical therapist. Massages performed with hand-held devices such as vibrators are not considered skilled in nature and are not reimbursable.
When Patients Should Be Discharged
Medical Record Documentation
The medial record should include:
All submitted documentation including initial evaluation, plan of care, treatment notes, progress notes and discharge summaries must be written and signed by the person performing the hands-on treatment of the patient. Therapist codes and stamps are not acceptable. Credentials such as PT or PTA must accompany the signature. Unsigned notes and documentation will not be accepted. When submitting documentation for review of isokinetic/computerized strength testing and ROM testing, the computerized printout must be included.
Appeals of Adverse Benefit Determinations
One appeal, either expedited or standard, may be performed for medical necessity non-certification determinations.
Expedited Appeal – An expedited appeal is available when there is an imminent or ongoing service requiring additional review of a non-certification determination. Appeal by telephone, facsimile or email and include additional information to be reviewed. Notification of the results of the appeal is made by telephone to the provider within 72 hours of receipt of the request with written notification to follow.
Standard Appeal – A standard appeal, due to a decision not to certify additional visits, must be made in writing by mail or facsimile by the provider. Include the patient's medical record as needed for the review if not submitted previously to Blue Cross and Blue Shield of Alabama.
Appeal requests should be mailed/faxed to:
Blue Cross and Blue Shield of Alabama
Post Office Box 362025
Birmingham, Alabama 35236
Fax Number: 205-220-0941
Telephone Number for Expedited Appeals: 205-220-7202
When requesting an appeal, additional information to support the medical necessity of the requested visits should be included.
When a non-certification decision is made without a physician conversation, a peer-to-peer conversation may be requested within 72 hours of the decision using the telephone number provided on the non-certification letter. If the original peer reviewer is not available, a peer alternate will be available to discuss the case. This does not count as an appeal. Any request beyond 72 hours of the decision is considered an appeal.
Preferred Physical Therapists Audits
A major strength of Blue Cross and Blue Shield of Alabama in managing healthcare costs is our ability to audit Preferred Providers and affect changes in utilization practice habits. Our contractual arrangements give us the right to audit medical records of patients of Preferred Physical Therapists in order to objectively evaluate the coding, billing and practice patterns, as well as the completeness of their medical records.
An audit can be triggered by external referrals from members, group administrators, anonymous tips, and even other physical therapists that feel that a particular physical therapist, group or facility is not in compliance with the program guidelines. An audit may also be triggered from internal claims and precertification data also.
If an offsite audit reveals unusual practice patterns or billing procedures that result in overpayments, refunds are required from the physical therapist and the amount is returned to the groups whose subscribers were affected by the incorrect practices. Any physical therapist having an unsatisfactory audit must immediately correct any problems. A follow up audit is performed to ensure that he/she is in compliance with the Preferred Physical Therapist guidelines. A second unsatisfactory audit can result in the therapist being removed from the Preferred Physical Therapy Program. These cases are referred to the Physical Therapist Advisory Committee for review. This committee is composed of five geographically distributed Preferred Physical Therapists.
CPT codes, descriptions and other data only are copyrighted © 2014 American Medical Association. All Rights Reserved. Applicable FARS/DFARS apply.