Provider Notice issued 06/30/12

Billing and Payment Changes for Occupational, Physical, and Speech Therapy Services

The purpose of this notice is to inform providers of upcoming changes related to billing and payment of therapy services.

Yearly Caps on Therapy Services for Adults Age 21 and Over

Effective July 1, 2012, HFS is implementing an annual cap of 20 visits per discipline per fiscal year (July 1 through June 30) for occupational, speech, and physical therapy for adult patients. This cap applies to all settings except inpatient.

Physical Therapy Changes

Ambulatory Procedures Listing (APL) Group 6 – Rehabilitation Services will be eliminated effective July 1, 2012. Effective with dates of service beginning July 1, 2012 through December 31, 2012, the department will allow hospitals to bill fee-for-service on the paper HFS 1443 claim form or the 837P electronic claim format for limited physical therapy services under the hospital’s fee-for-service NPI.

Reimbursement for speech and occupational therapy services remains the same and is based on the Therapy Fee Schedule. Physical therapy will also be paid based on the Therapy Fee Schedule.

Physical Therapy Billing Requirements

Billable CPT Codes: 97001 and 97110. These codes must be billed with modifier GP. Prior approval is required for adults when billing CPT code 97110. CPT code 97001 (Physical Therapy Evaluation) will not require a prior approval or be counted in the annual cap of 20 visits per fiscal year.

Effective with dates of service on and after January 1, 2013, physical therapy services must be billed under the name and NPI of the therapist who performed the service.

Occupational and Speech Therapy Billing Change

Hospitals have historically been allowed to bill fee-for-service under a fee-for-service NPI for occupational and speech therapy services. Reimbursement for occupational and speech therapy services are reimbursed based on the Therapy Fee Schedule. Effective with dates of service on and after January 1, 2013, occupational and speech therapy must be billed fee-for-service under the name and NPI of the therapist who performed the service.

Occupational Therapy Billing Requirements

Billable CPT Codes: 97003 and 97110. These codes must be billed with modifier GO. Prior Approval is required for adults when billing CPT code 97110. CPT code 97003 (Occupational Therapy Evaluation) will not require prior approval or be counted in the annual cap of 20 visits per year.

Speech Therapy Billing Requirements

Billable CPT Codes: 92506 and 92507. These codes must be billed with modifier GN. Prior approval is required for adults when billing CPT code 92507. CPT code 92506 (Evaluation of Speech) will not require prior approval or be counted in the annual cap of 20 visits per year.

Prior Approval Required for All Adult Therapy Services

Effective with dates of service on and after July 1, 2012, providers must submit prior approval requests for all therapy services for adults 21 years of age and older. This includes physical therapy services billed fee-for-service under the hospital NPI for the time period July 1, 2012 through December 31, 2012. Prior approval will now be required for therapy treatment services needed in the sixty (60) day calendar period immediately following discharge from an acute care or rehabilitation hospital.

Modifier U6

The reporting of modifier U6 in conjunction with billing for therapy services will be eliminated on July 1, 2012. Modifier U6 was used by all therapies providing services within 60 days of hospital discharge.

Enrollment of Salaried Occupational, Speech, and Physical Therapists

HFS encourages hospitals to initiate the enrollment process for the non-enrolled salaried occupational, speech, and physical therapists as soon as possible. When enrolling, the therapist may choose to designate the hospital as a payee.

Enrollment information is available for downloading from the department’s Web site. Providers may also contact the Provider Participation Unit at:

Illinois Department of Healthcare and Family Services

Provider Participation Unit

P.O. Box 19114

Springfield, IL 62794-9114

E-mail: hfs.ppu@illinois.gov

Telephone: 217-782-0538

Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs