Provider Notice issued 11/02/12

Update to Therapy Services Provided by Hospitals and APL Policy Change

This notice is an update to the previous hospital notice dated June 30, 2012 that identified payment and billing changes for hospital therapy services effective July 1, 2012.

Physical Therapy Reimbursement Change

The Joint Committee on Administrative Rules (JCAR) recently suspended an emergency amendment to 89 Illinois Administrative Code Section 148.140 (removal of APL Group 6 –Rehabilitation Services). As a result of this, effective with dates of service on and after July 1, 2012, HFS will revert the payment rate for physical therapy procedures to the rate hospitals were paid under the APL:  $115.00 per visit for general hospitals and $130.00 per visit for children’s hospitals and rehabilitation hospitals. The department will apply the 3.5% SMART Act rate reduction for hospital outpatient services to these claims.

The department will adjust to the higher rate any claims that have already been adjudicated at the lesser payment amount.

Public Act 097-0689(pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, mandated a cap of 20 visits per year for physical therapy services for adults age 21 and over. In order to comply with that mandate for adults, HFS will still require hospitals to submit the HFS 1409 Prior Approval Request for procedure code 97110. CPT code 97001 (Physical Therapy Evaluation) does not require prior approval and does not count in the annual cap of 20 visits per fiscal year. Hospitals will continue to bill physical therapy procedures with modifier GP on the paper HFS 1443 claim form or the 837P electronic claim format under the hospital’s fee-for-service NPI.  

Update to Enrollment of Salaried Therapists

The June 30, 2012 notice to hospitals stated hospitals had to enroll their salaried physical, occupational, and speech therapists by December 31, 2012, in order for claims to be billed under the individual therapist’s name and NPI effective January 1, 2013. HFS is suspending the requirement for hospitals to enroll their salaried physical, occupational, and speech therapists.  Hospitals will continue to bill physical, occupational, and speech therapy services under the hospital’s fee-for-service NPI.

Change in APL Policy Effective July 1, 2012

When any service listed in the APL is performed on a given day, all services provided on that day (excluding the exceptions below) must be billed on a single outpatient institutional claim.

The all-inclusive APL rate has been considered to cover all services provided by salaried hospital personnel, all drugs administered and/or provided for take home use, all equipment and supplies used for diagnosis and/or treatment, and all X-ray, laboratory and therapy provided to the patient on the same day.

Exceptions to this policy have been:

• Hospitals are allowed to bill separately on a fee-for-service basis for a salaried physician providing direct patient care. This claim must be billed under the salaried physician’s name and NPI.

• Chemotherapy services provided in conjunction with radiation therapy may be billed fee-for-service.

Effective with dates of service on and after July 1, 2012, hospitals may bill fee-for-service for any therapy service (physical, occupational, or speech) in addition to any institutional APL procedure for the same date of service.                    

Any questions regarding this notice may be directed to your hospital’s medical assistance consultant in the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Programs