Provider Notice issued 10/31/13

Therapy Prior Approval Request Change and Therapy Modifier Billing Reminder

The purpose of this notice is to advise therapy providers of a change in identifying the Quantity submitted on the HFS 1409 Prior Approval Request form, and to reaffirm modifier billing instructions for approved therapy services. Please note, this information is not applicable to nursing facility residents who receive therapy as part of the facility's Medicaid per diem.

• HFS 1409 Therapy Prior Approval Completion Change

As a result of Public Act 097-0689(pdf), referred to as the Save Medicaid Access and Resources Together (SMART) Act, HFS implemented a cap of 20 visits per discipline per fiscal year (July 1- June 30) for physical, occupational and speech therapy services for participants 21 years of age and older. Therapy evaluations are not counted as part of the cap. Currently, therapy providers request physical, occupational, and speech therapy services in quarter-hour (15-minute) units. In order to streamline the approval process, and better comply with the provisions of the SMART Act, effective with the date of this notice, providers are instructed to base the Quantity field on HFS 1409 on the number of therapy visits, not the number of quarter-hour units. The HFS 1409i completion instructions have been updated to reflect that therapy providers must request the Quantity in visits.

Upon approval of Prior Approval Requests, HFS issues an authorization letter to the provider. The Quantity noted in the authorization letter is the number of visits approved, not the number of units.

• Claim Submission Requirements

Claim submission requirements remain the same. As an example, an approval of 20 visits would allow up to 80 units (20 hours) to be billed. At this time, the claim should still reflect the number of quarter-hour units utilized for the therapy visit. As is current policy, a maximum of four (4) units are allowed per date of service for therapy. The department will not reimburse for both an evaluation and a therapy service code of the same discipline on the same date of service. Providers are reminded to identify by modifier the type of therapy billed. Claims may not process at the correct reimbursement if the modifier is not identified with the procedure code billed.

• GN - Required when billing Speech Therapy services procedure code 92507 or evaluation code 92506

• GO - Required when billing Occupational Therapy services procedure code 97110 or evaluation code 97003

• GP - Required when billing Physical Therapy services procedure code 97110 or evaluation code 97001

As a reminder, hospitals billing fee-for-service for physical therapy procedures are reimbursed per visit at the previous payment rate they were assigned under the Ambulatory Procedures Listing (APL), regardless of the number of units billed on the claim.

Any questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565, option 5, then option 2.

Theresa A. Eagleson, Administrator

Division of Medical Programs