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| This section provides policy and billing information for outpatient rehabilitative and therapeutic services including physical therapy, occupational therapy, speech-language pathology, and audiology. |
| Comprehensive Outpatient Rehabilitation Facilities (CORFs) |
| Indian health service (IHS) |
| Long term care facilities |
| Medicare certified rehabilitation agencies |
| Occupational therapists |
| *Occupational therapy assistants |
| *Physical therapist assistants |
| Rural health clinics (RHCs) |
| Speech-language pathologists |
Audiologists
An individual is eligible to enroll as an audiologist if he/she meets the qualifications of the Minnesota Department of Health to be licensed or where applicable, licensed or registered by the state in which he/she practices. If the state does not license providers of audiology services, the applicant for enrollment with MHCP must demonstrate that he/she meets the CCC and practicum requirement listed below: |
| Holds a Certificate of Clinical Compliance (CCC requirement) from the American Speech Hearing and Language Association (ASHA); OR meets the following clinical practicum (practicum requirement) standards: |
| Has demonstrated a successful completion of a minimum of 350 clock-hours of supervised clinical practicum (or is in the process of accumulating such experience); |
| Has performed not less than nine months of supervised full-time audiology services after obtaining a masters or doctoral degree; and |
| Has successfully completed a national exam in audiology approved by the Secretary. |
| Audiologists employed by outpatient hospitals, skilled nursing facilities, comprehensive outpatient rehabilitation facilities (CORFs), physician clinics, Medicare certified rehabilitation agencies, IHS, or RHCs may enroll with MHCP. |
Comprehensive Outpatient Rehabilitation Facilities (CORFs)
A non-residential facility that is established and operated exclusively to provide diagnostic, therapeutic and restorative services to outpatients for the rehabilitation of injured, disabled, or sick persons, at a single fixed location, by or under the direction of a physician and that meets the conditions of participation. Additionally, a facility that qualifies as a CORF may be enrolled to provide mental health services. |
Occupational Therapists (OTs)
An individual certified by the National Board for Certification of Occupational Therapy as an occupational therapist and, where applicable, licensed by the state in which he/she practices. Occupational therapists practicing in Minnesota must comply with state licensure requirements. Occupational therapists employed by outpatient hospitals, skilled nursing facilities, CORFs, physician clinics, Medicare certified rehabilitation agencies, IHS, or RHCs may enroll with MHCP. |
Physical Therapists (PTs)
An individual who is a graduate of a program of physical therapy approved by both the Commission on Accreditation in Physical Therapy Education (CAPTE) and the American Physical Therapy Association or its equivalent. Physical therapists practicing in Minnesota must comply with state licensure requirements. Physical therapists employed by outpatient hospitals, skilled nursing facilities, CORFs, physician clinics, Medicare certified rehabilitation agencies, IHS, or RHCs may enroll with MHCP. |
Rehabilitation Agencies
A provider certified by Medicare to provide restorative, specialized maintenance therapy, and social or vocational adjustment services. Services provided by Medicare certified rehabilitation agencies must be provided at: |
| A site surveyed by the Minnesota Department of Health and certified according to Medicare standards, or |
| A site that meets State Fire Marshall standards, as documented in the providers' records, or |
| The recipient's residence |
Speech-language Pathologists
An individual is eligible to enroll as a speech-language pathologist if he/she has a certificate of clinical competence in speech-language pathology from the American Speech and Hearing Association and are required to hold a current license with the Minnesota Department of Health when practicing in Minnesota. Speech-language pathologists practicing in another state must comply with the licensure/certification of the state in which they practice. |
| Speech-language pathologists employed by outpatient hospitals, skilled nursing facilities, CORFs, physician clinics, Medicare certified rehabilitation agencies, IHS, or RHCs may enroll with MHCP. |
Therapists in Private Practice
Occupational therapists, physical therapists, speech-language pathologists and audiologists who are in private practice must maintain a private office even if services are furnished in a recipients home. A private office is space that is leased, owned, or rented by the practice and used for the exclusive purpose of operating the practice. For example: a private practice therapy practitioner may not furnish covered services in a skilled nursing facility. Therefore, if a private practice therapy practitioner wishes to locate his/her private office on site at a nursing facility, the private office space may not be part of the Medicare participating SNF space and the therapist's services may be furnished only within the therapist's private office space. |
Physical Therapist Assistants (PTAs) and Occupational Therapy Assistants (OTAs)
MHCP reimburses providers for the services of a physical therapist assistant or an occupational therapy assistant when services are provided under the direction of a therapist. The therapist must provide on-site observation of the treatment and documentation of its appropriateness at least every sixth treatment session when services are provided by physical therapist assistants or occupational therapy assistants. Evaluations and reevaluations will not be reimbursed if provided by physical therapist assistants or occupational therapy assistants. |
| Physical Therapist Assistant (PTA): A person graduated from a physical therapist assistant educational program accredited by the Commission on Accreditation in Physical Therapy Education or a comparable accrediting agency. Physical therapist assistants practicing in Minnesota must comply with state licensure requirements. |
| Occupational Therapy Assistant (OTA): A person who has successfully completed all academic and fieldwork requirements of an occupational therapy assistant program approved or accredited by the Accreditation Council for Occupational Therapy Education and certified by the National Board for Certification of Occupational Therapy as an occupational therapy assistant, and where applicable, is licensed by the state in which he/she practices. Occupational therapy assistants must comply with state licensure requirements. |
| Practitioners with Temporary License |
| Speech-Language Pathology and Audiology Supervision during Fellowship Year: A person completing the clinical fellowship year required for certification may provide audiology services or speech-language pathology services under the supervision of an audiologist or speech-language pathologist but is not eligible to enroll as a provider. See specific requirements regarding supervision during clinical fellowship year. Speech-language pathologists or Audiologists who hold a valid temporary license to practice are not eligible to enroll as MHCP providers |
| Physical therapists with a valid temporary permit to practice and occupational therapists with a valid temporary license to practice may provide services under the supervision of a licensed physical therapist/occupational therapist, but may not enroll as MHCP providers. |
Therapy Students Providing Care
Only the direct one-to-one patient contact services of the qualified therapist as defined in this section are billable when a student is involved in the delivery of services. Services performed by a student are not reimbursed even if provided under line of sight supervision of a qualified therapist. Qualified therapists may bill and be paid for the provision of services in the following scenarios: |
| A qualified therapist is present and in the room for the entire session. The student participates in the delivery of services when the qualified therapist is directing the treatment, making the skilled judgment, and is responsible for the assessment and treatment. |
| A qualified therapist is present in the room guiding the student in service delivery when the therapy student is participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time. Documentation of the therapy service must clearly indicate the qualified therapist was present in the room, guiding the student in the delivery of the service(s) and not simply on the premises. The therapist must be focused on the services provided by the student and not involved with other activities or other patients. |
| The qualified therapist is responsible for the services delivered and required to sign all the documentation. The student may complete the documentation as part of their education/hands-on training, but the qualified therapist is responsible for the services and the documentation and is required to sign all the documentation. In signing the documentation, the therapist indicates they have read it and are responsible for its contents, which must clearly indicate the services were provided by the student with the therapist directing them. The student may also sign the documentation but it is not required for payment. |
| Medical Assistance (MA) |
| Outpatient rehabilitative and therapeutic services, physical therapy, occupational therapy and speech-language pathology, require no medical authorization from July 1, 2011, to October 1, 2013. |
| Audiology service have an annual threshold, the number of units of service available without authorization renew January 1 of each year. |
| Recipients may require a greater number of evaluations, modalities or procedures than are available in the annual service threshold. Recipients may receive additional medically necessary services with authorization. |
| Medicare crossover claims for coinsurance and/or deductible do not debit against the audiology annual thresholds |
| Third-party liability (TPL) claims submitted to MHCP for payment debit against the audiology annual thresholds. Providers are not required to bill MHCP; if the provider is aware the TPL payment will equal or exceed the MHCP payment, providers may consider not billing MHCP because all claims debit against the threshold, even if the claim pays zero dollars. |
| To be covered as a rehabilitative and therapeutic service, occupational therapy and physical therapy must be prescribed by a physician or other licensed practitioner of the healing arts and must require the skills of: |
| An occupational therapist |
| A physical therapist assistant who is working under the direction of a physical therapist, or |
| An occupational therapy assistant working under the direction of an occupational therapist |
| To be covered as a rehabilitative and therapeutic service, speech-language pathology and audiology services require written referral by a physician or other licensed practitioner of the healing arts, or in the case of a long-term care facility resident on the written order of a physician; and must require the skills of: |
| A speech-language pathologist |
| An individual completing the clinical fellowship year required for certification as a speech-language pathologist, or |
| An individual completing the clinical fellowship year required for certification as an audiologist and working under the supervision of an audiologist |
| Treatment must be specified in a Plan of Care that is reviewed and revised as medically necessary by the recipient's attending physician, or other licensed practitioner of the healing arts, at least once every 60 days (see Plan of Care for additional requirements). MHCP accepts electronic signatures for this requirement. |
| The recipient's functional status must be expected by the physician or other licensed practitioner of the healing arts as defined in this section, to progress toward or achieve the objectives in the recipient's plan of care within a 60-day period |
| If the service is a Medicare covered service, and is provided to a recipient who is eligible for Medicare, the plan of care must be reviewed at the intervals required by Medicare. |
| Providers must comply with Medicares site requirements when services are provided to Medicare eligible recipients. |
| Effective January 1, 2012, specialized maintenance therapy coverage is limited to MHCP recipients age 20 and under. Specialized maintenance therapy is a health service specified in the recipient's plan of care by a physician, or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law, that is necessary for maintaining a recipient's functional status at a level consistent with the recipient's physical or mental limitations, and that may include treatments in addition to rehabilitative nursing services. Specialized maintenance therapy is covered only when provided by: |
| A physical therapist assistant |
| An occupational therapist |
| An occupational therapy assistant, or |
| A speech-language pathologist |
| Specialized maintenance therapy must be specified in a Plan of Care that meets the requirements of this section, and provided to recipients whose condition cannot be maintained or treated only through: |
| Rehabilitative nursing services, or |
| Services of other care providers, or |
| By the recipient because the recipient's physical, cognitive or psychological deficits result in: |
| Spasticity or severe contracture that interferes with the activities of daily living or the completion of routine nursing care, or has resulted in decreased functional ability compared to the recipient's previous level of function |
| A chronic condition that results in physiological deterioration and that requires specialized maintenance therapy services or equipment to maintain strength, range of motion, endurance, movement patterns (functional mobility such as gait, transfers, ambulation, bed/chair mobility), activities of daily living, cardiovascular function, integumentary status, or positioning necessary for completion of the recipient's activities of daily living, or decreased abilities relevant to the recipient's current environmental demands |
| Specialized maintenance therapy must have expected outcomes that are: |
| Transferable to the recipient's current or anticipated environment, such as home, school, community, work |
| Consistent with community standards |
| Specialized maintenance therapy must meet at least one of the following characteristics: |
| Prevent deterioration and sustain function |
| Provide interventions, in the case of a chronic or progressive disability, that enable the recipient to live at the recipient's highest level of independence, or |
| Provide treatment interventions for recipients who are progressing but not at a rate comparable to the expectations of restorative care |
| Providers must document all evaluations, and re-evaluations, services provided, recipients progress, attendance records, and discharge plans. Documentation must be kept in the recipient's records. Documentation must demonstrate that rehabilitative and therapeutic services are: |
| Medically necessary as determined by prevailing community standards or customary practice and usage |
| Appropriate and effective for the recipients medical needs |
| Timely, considering the nature and present medical condition of the recipient |
| Provided by a provider with appropriate credential |
| The least expensive, appropriate alternative available, and |
| An effective and appropriate use of MHCP funds |
| Rehabilitative and therapeutic services must be documented as specified in this section whether MHCP is the primary or secondary payer. |
| Example: Recipient has other third-party insurance. Providers must comply with MHCP documentation standards even if other insurance documentation standards are not the same. |
| Refer to the professional documentation guidelines for your therapy discipline for guidance on effective documentation: |
| Refer to the Medicare Guidelines for Documentation when providing treatment to a recipient who is dually eligible for Medicare and Medicaid |
Plan of Care
Rehabilitative and therapeutic services, specialized maintenance therapy and audiology services must be provided under a written Plan of Care (POC) that specifically states: |
| The recipients medical diagnosis and any contraindications to treatment |
| A description of the recipients functional status/limitations |
| Treatment plan including interventions to be provided |
| Outcomes of the rehabilitative and therapeutic service, which include: |
| Treatment goals that are: |
| Projected frequency and duration of treatment |
| Plans for discharge from treatment |
| A description of the recipient's progress toward the outcomes for subsequent POC: |
| Collaboration with other professionals/services |
| Progress toward goals with updating as indicated |
| Modifications to the initial plan of care |
| Plans for continuing care |
| Record of Service: The recipients record of service must show: |
| The date, type, length, and scope of each service |
| The name(s) and title(s) of the person(s) providing each service |
| The name(s) and title(s) of the person(s) supervising or directing the care, and |
| A statement, every 30 days, by the therapist providing or supervising the services that the therapy's nature, scope, duration and intensity are appropriate to the medical condition of the recipient |
| Services for physical or occupational therapy provided by a person, who was issued a temporary permit for physical therapy or a temporary license for occupational therapy and the temporary permit or license has expired |
| Services for speech-language pathology or audiology services provided by a person whose temporary license has expired |
| * Services for contracture that are not severe and do not interfere with the recipient's functional status or the completion of nursing care as required for licensure of the LTC facility |
| * Ambulation of a recipient who has an established functional gait pattern |
| * Services for conditions of chronic pain that do not interfere with the recipient's functional status and that can be treated by routine nursing measures |
| * Services for activities of daily living when performed by the therapist, therapy assistant or therapy aide |
| * Bowel and bladder retraining programs |
| Specialized maintenance therapy for MHCP recipients age 21 and over (effective January 1, 2012) |
| Art and craft activities for the purpose of recreation |
| Service not medically necessary |
| Service not documented in the recipient's health care record |
| Service not part of the recipient's plan of care |
| Service specified in a plan of care that is not reviewed and revised as medically necessary by the recipients attending physician or practitioner of the healing arts as defined in this section |
| Service that are not designed to improve or maintain the functional status of a recipient with a physical impairment or a cognitive or psychological deficit |
| Service by more than one provider of the same type for the same diagnosis unless the service is provided by the school district as specified in the recipient's IEP |
| A rehabilitative and therapeutic service that is denied Medicare payment because of the provider's failure to comply with Medicare requirements |
| Vocational or educational services, including functional capacity evaluations, except as provided under IEP-related services |
| Record keeping, documentation, and travel time (the transport and waiting time of a recipient to and from therapy sessions) |
| Services provided by a rehabilitation agency that take place in a sheltered workshop, Day Training and Habilitation center (DT&H), Day Activity Center (DAC), or a residential or group home which is an affiliate of the rehabilitation agency |
| *Yearly assessments of LTC residents to meet OBRA regulations; and |
| Training or consultation provided by an audiologist to an agency, facility, or other institution. |
| * These items are considered rehabilitative nursing and are part of the LTC facility per diem payment. |
| Bill using MNITS Interactive 837P or 837I |
| Enter the NPI of the referring/ordering physician, or other practitioner of the healing arts on claims for OT, PT, SLP and audiology. Referring/ordering physicians must be enrolled with MHCP. |
Codes and Modifiers
MHCP uses outpatient rehabilitative service codes as defined in CPT/HCPCS billable in timed units (15 minutes, 30 minutes, 1 hour). Bill outpatient rehabilitative services with codes that most closely describe the service provided. |
Timed Codes
Do not bill for services represented by 15 minute timed codes when performed for less than 8 minutes on any date of service. Follow these guidelines: |
| 1 unit for a service represented by a 15 minute timed code when at least 8 minutes through 22 minutes are spent directly with the recipient |
| 2 units if the duration of the service equals 23 minutes through 37 minutes |
| 3 units if the duration of the service equals 38 minutes through 52 minutes |
| 4 units if the duration of the service equals 53 minutes through 67 minutes |
| 5 units if the duration of the service equals 68 minutes through 82 minutes |
| 6 units if the duration of the service equals 84 minutes through 97 minutes |
| Bill only direct patient contact by the provider as time the patient is treated |
| Bill CPT/HCPCS codes that do not have a timed component/unit assigned are one unit per visit, regardless of the time spent during the session |
| Bill only one unit for any date of service that is a per visit/session code |
| The following modifiers are required to indicate the therapy discipline delivering the outpatient rehabilitative services and on authorization requests: |
| GN - speech-language pathology |
| GO - occupational therapy |
| U7 modifier: Required to indicate the service was provided by a physical therapist assistant or occupational therapy assistant when a physical therapist or occupational therapist, under whose direction the assistant was working, was not on the premises. U7 is not required on authorization requests. |
| 59 modifier: Follow the National Correct Coding Initiative (NCCI) instructions for use of the 59 modifier on claims for codes that may not be billed together unless performed on a different anatomic site or represents a different encounter. The 59 modifier is not required on authorization requests. |
| UC modifier: Use only to indicate that the therapy service provided was specialized maintenance therapy. Document specialized maintenance therapy in the patients record. |
| Telemedicine modifiers: Use the following modifiers to indicate services delivery via telemedicine applications. Only those services that are appropriate for delivery via telemedine may be billed as such. |
| GQ: Services delivered via asynchronous telecommunication system (via computer) |
| GT: Services delivered via interactive audio and video telecommunication system |
| Use the correct HCPCS code and appropriate modifier from the Casting & Strapping Services/Supplies chart to bill therapeutic supplies fabricated by the therapist, such as splints, casts, and adaptive aids. Do not bill for ready-made or pre-fabricated supplies that can be obtained from a medical supplier. |
| Include the most relevant ICD-9 diagnosis code for the provided service |
| Co-therapy: Split the time between therapy disciplines for billing purposes when services are delivered to a recipient by two or more therapy disciplines in the same block of time. Total time billed should not exceed the actual length of time spent with the patient |
| Always follow Medicare guidelines for MHCP recipients who are dually eligible for Medicare and Medicaid when providing Medicare covered services |
| Bill only for services you provide using your individual NPI number. |
| Enter the NPI of the facility (physician clinic, outpatient hospital, rehabilitation agency, or CORF) as the Pay-to-Provider when billing rehabilitative services provided in these settings |
| Enter the therapists NPI as the rendering provider |
| Long-term care facilities may provide rehabilitative services to both residents and members of the community, employing either therapists employed by the LTC or by contracting with an outside vendor such as a rehab agency or therapist in private practice. |
| Services must be provided on the LTC premises |
| Rehabilitative services included in the LTC per diem rate may not be billed as an outpatient service |
| LTC facilities located in Minnesota no longer include rehabilitative services in their per diem |
| Bill services provided to recipients who are also eligible for Medicare following Medicares requirements |
| The LTC facility must bill for services provided by its employees |
| Services provided by contracted outside vendors may be billed by either the vendor or the LTC facility; however, the provider billing for and receiving payment for services is responsible for the accuracy of the claims and for maintaining patient records that fully disclose the extent of the benefits provided. |
| Audiologic Evaluation: An assessment administered by an audiologist or otolaryngologist to evaluate communication problems caused by hearing loss. |
| Direction: The actions of a physical or occupational therapist who instructs the physical therapist assistant or occupational therapy assistant, monitors the assistant's provision of services, and provides documentation of on-site observation of the treatment and its appropriateness at least every sixth treatment session for each recipient when treatment is provided by a physical therapist assistant or an occupational therapy assistant and meets all supervisory requirements of the therapy disciplines respective licensure requirements. |
| Functional Status: The ability to carry out the tasks associated with daily living. |
| Long Term Care Facility (LTC): Nursing facility (NF), skilled nursing facility (SNF), or intermediate care facility for persons with developmental disabilities (ICF/DD). |
| Otolaryngologist: A physician specializing in diseases of the ear and larynx who is certified by the American Board of Otolaryngology or eligible for board certification. |
| Practitioner of the Healing Arts: For the purposes of this section, practitioner of the healing arts includes any person who engages in, or holds out to the public as being engaged in, the practice of medicine or surgery, the practice of osteopathy, or other practitioner of the healing arts whose scope of practice under state law includes diagnosis of disease or health condition and prescribing treatment; e.g., physician assistant, nurse practitioner, podiatrist, oral surgeon, dentist, optometrist. |
| Rehabilitative and Therapeutic Services: Restorative therapy, specialized maintenance therapy, and rehabilitative nursing services. |
| Rehabilitative Nursing Services: Nursing homes must have active program of rehabilitation nursing care directed toward assisting each resident to achieve and maintain the highest practicable physical, mental and psychosocial well-being according to the comprehensive resident assessment and plan of care. Continuous efforts must be made to encourage ambulation and purposeful activities. |
| Restorative Therapy: A health service specified in the recipient's plan of care, ordered by a physician or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law, and that is designed to restore the recipient's functional status to a level consistent with the recipient's physical or mental limitations. |
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