Physical Therapy
The Current Procedural Terminology (CPT) physical medicine and rehabilitation codes, as well as other services that require supervised/constant attendance modalities, wound therapy, testing, assessments, evaluations, and re-evaluation services may be submitted by a physical therapist.
Coding Rules
- Professional Claims: Each line of service submitted by a Physical Therapist must include modifier GP.
- Outpatient Facility Claims: Each line of service submitted with revenue code 042X must include a GP Modifier.
Occupational Therapy
The CPT physical medicine and rehabilitation codes, as well as other services such as splints, strapping, testing, assessments, evaluations and re-evaluation services may be submitted by an occupational therapist.
Coding Rules
- Professional Claims: Each line of service submitted by an Occupational Therapist must include modifier GO.
- Outpatient Facility Claims: Each line of service submitted with revenue code 043X must include a GO Modifier.
Speech Therapy
Speech-Language Pathologist should use appropriate CPT codes for their speech therapy services and for evaluation and treatment of swallowing dysfunction.
If a speech evaluation is done over a period of two days and only one report is generated upon completion of the evaluation, submit the evaluation code only once with the date of service the evaluation was completed.
Coding Rules:
- Professional Claims: Each line of service submitted by a Speech-Language Pathologist must include modifier GN.
- Outpatient Facility Claims: Each line of service submitted with revenue code 044X must include a GN Modifier.
Limitations and Exclusions
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, payment integrity edits and medical necessity.
- Mandated or legislative required criteria will always supersede.
In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.
Cross References
- Physical Therapy | Medical Policy | BCBSND
- Occupational Therapy | Medical Policy | BCBSND
- Speech Therapy | Medical Policy | BCBSND
- Home Health Services | Reimbursement Policy | BCBSND
- Hospice Services | Reimbursement Policy | BCBSND
- Inpatient Skilled Nursing Facility Billing Guidelines | BCBSND
- Modifier 25, 27, 59, FT, XE, XP, XS & XU | Reimbursement Policy | BCBSND
- Telehealth Services | Reimbursement Policy | BCBSND
- BCBSND Provider Manual
- CMS Internet Only Manual (IOM) 100-04, Chapter 4, Section 20.6
- CMS Internet Only Manual (IOM) 100-04, Chapter 5, Section 20.1
History
Date
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Updates
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11/15/2023
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Created Physical, Occupational, and Speech Therapy Modifiers
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7/22/2024
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Annual policy review completed. Updated document to change “billing” to “coding”. Added Policy Application section. Removed PT and OT therapy section definition as this is outlined in the Medical Policy and this policies definition. Removed E/M reference.
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