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Preferred Physical Therapy

A new physical therapist that joins the Preferred Physical Therapy (PPT) 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 members contract benefit.

Standard Appeal – Requests for standard appeal or a decision not to certify additional visits must be made in writing by mail or facsimile by the provider and include the medical records needed for the review if not submitted previously to Blue Cross and Blue Shield of Alabama.

Covered Services
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, and therefore 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.

Non-Covered Services

Preferred Physical Therapists are responsible for notifying the patient of services that are not medically necessary for treatment of his/her condition. Within this document 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.

Covered Providers

Non-Covered Providers of Physical Therapy Services
Athletic trainers, exercise physiologists, massage therapist, RNs, LPNs, certified strength trainers, secretaries, and office personnel are not considered covered providers. Services performed by these providers are not covered.

Filing for these kinds of services, as well as occupational and speech therapy services, under the physical therapist NPI is not acceptable and is not reimbursable.

Precertification

Preferred Physical Therapists 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 statement for each visit indicating that they have 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, a completed form should be submitted to:

Blue Cross and Blue Shield of Alabama
Fax Number: 205 220-0941
Attention: Physical Therapy Precertification

Click here to view a sample of the precertification form. 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. Notification of the determination will be by letter or by facsimile.

Precertification requests received after 2:00 p.m. will be considered as received the following business day.

Exceptions

Precertification is not required for:

CPT Codes
Listed below are a few of the procedure codes covered under the PT Network. Special care should be given in reporting and documenting these services.

97140 Manual therapy techniques (mobilization, manipulation, manual lymphatic drainage, and manual traction), one or more regions, each 15 minutes.

Treatment must be diagnosis related and documentation must support proper billing of 97140 and contain the following:

97010 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

97597 Removal of devitalized tissue from wound(s), selective debridement, without anesthesia (e.g., high pressure water jet with/without suction, sharp selective debridement with scissors, scalpel and forceps), with or without topical application(s), wound assessment, and instruction(s) for ongoing care, may include use of a whirlpool, per session; total wound(s) surface area less than or equal to 20 square centimeters

97598 Removal of devitalized tissue from wound(s); selective debridement, without anesthesia (e.g., high pressure water jet, sharp selective debridement with scissors, scalpel and tweezers), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

97605 Negative pressure wound therapy (e.g., 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 (e.g., 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

97750 Physical performance test or measurements (musculoskeletal, functional capabilities), with written report. Blue Cross and Blue Shield of Alabama will allow the billing initially of 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.

97113, 97530, 97110 Documentation must justify billing of multiple services.

97124 In order to be considered for coverage when billing therapeutic massage [Physicians’ Current Procedural Terminology (CPT) code 97124], 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. Massage performed with hand-held devices such as vibrators is not considered skilled in nature and is 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 P.T. or P.T.A. 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 Determination Not to Precertify

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 e-mail with additional information to be included in the review. Notification of the results of the appeal will be made by telephone to the provider within 24 hours of receipt of the request with written notification to follow.

Standard Appeal – Requests for standard appeal or a decision not to certify additional visits must be made in writing by mail or facsimile by the provider and include the medical records needed for the review if not submitted previously to Blue Cross and Blue Shield of Alabama.

Appeal requests should be mailed 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 - 205-220-6356 or 205-220-7202

When requesting an appeal, additional information to support the medical necessity of the requested visits should be included. Appeals should not be requested until covered visits are used. Appeals can only be requested when no additional treatments have been confirmed. There are not appeals of partial confirmation or approvals. For instance, if eight additional visits are requested by a Preferred Physical Therapist and four visits are approved by Blue Cross and Blue Shield of Alabama, the physical therapist may not request additional visits if he/she determines additional treatment is necessary.

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 noncertification

letter. If the original peer reviewer is not available, a peer alternate is 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 health care costs is our ability to audit Preferred Providers and effect 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 off-site 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.