Description

Always Therapy Services are eligible therapy procedures (i.e., therapy modalities Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST)) performed by a certified therapist. Such procedure codes are assigned a therapy indicator of "5" by CMS.

Practice Expense (PE) is the portion of the resources used in a facility setting that addresses the cost of the facility, including the building, supplies and non-provider staff costs.

Relative Value Unit (RVU) consists of the work expense, practice expense, and malpractice expense.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) allows professional and facility reimbursement for multiple therapy services performed on the same day, according to the criteria outlined in this policy.

Reimbursement Guidelines

Multiple Always Therapy services will be subject to a 50% multiple procedure payment reduction (MPPR) on the Practice Expense (PE) Relative Value Unit (RVU). 

Professional and facility reimbursement will be based on the following:

• Primary procedure, indicated by the highest PE RVU – 100% of the PE RVU
• Secondary procedure(s) – 50% of the PE RVU 

The multiple therapy service reduction applies across all therapy modalities.

Therapy services provided by physicians, nonphysician practitioners, physical and occupational therapists, and speech language pathologists in private practice must be appropriately submitted with Modifier GN, GO, or GP when the services are performed under a therapy plan of care. See Modifier Guidelines for more information.

Note: Professional reimbursement MPPR applies to multiple therapy services performed on the same day by the same provider ID. Facility reimbursement MPPR applies to multiple therapy services performed on the same day at the same hospital system with the same federal tax ID.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com. 

Related policy

Bundling Guidelines

Modifier Guidelines

References

Centers for Medicare and Medicaid Services (CMS) Transmittal #1194
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1194OTN.pdf

Centers for Medicare and Medicaid Services, Physician Fee Schedule (PFS)
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-ValueFiles

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Blue Cross and/or Blue Shield Plan Members who seek care from the NC service area). 

This policy relates only to the services and/or supplies described herein. Please refer to the applicable Member’s Benefit Booklet for availability of benefits. Member’s benefits may vary according to benefit design; therefore, Member benefit language should be reviewed before applying the terms of this policy.