Section 20-2-II - REIMBURSEMENTA.Guidelines1. Visits for therapy may not exceed one visit per day without prior approval from the payer.2. Therapy exceeding fifteen (15) visits or thirty (30) days, whichever comes first, must have prior authorization from the payer for continuing care. It must meet the following guidelines: a. The treatment must be medically necessary. b. Prior authorization may be made by telephone. Documentation should be made in the patient's medical record indicating the date and name of the payer representative giving authorization for the continued therapy.3. Reimbursement is limited to no more than four (4) therapies concurrently at the same visit. In the event of multiple treatment areas, an additional four (4) therapies per treatment day may be allowed at the payer's discretion and with pre-authorization. In the event of multiple treatment areas, the second and subsequent areas are subject to the multiple procedure rule.4. Payment for 97010, which reports application of hot or cold packs, is bundled into payment for other services. Separate reimbursement for hot and cold packs will not be allowed in the treatment of work-related injury/illness.5. Only one (1) work hardening or work conditioning program is reimbursed per injury.6. The Physical Therapist Assistant or Occupational Therapist Assistant shall be reimbursed at eighty-five percent (85%) of the maximum allowable for the procedure. Mississippi modifier "M3" should be attached to the appropriate CPT code(s) when billing services rendered by a Physical Therapist Assistant or an Occupational Therapist Assistant.7. NCCI edits or other bundle/unbundle edits do not apply to the CPT codes in the Therapeutic Services section, other than the stated rules provided in this section.B.Treatment Areas1. Spinal areas are recognized as the following five distinct regions: * Cranial;
* Cervical;
* Thoracic;
* Lumbar; and
* Sacral.
Transitional areas of the spine are not recognized as distinctly different areas (e.g., cervicothoracic, lumbosacral).
3. Upper extremity (either left or right) is recognized as the following six distinct regions: * Shoulder;
* Upper arm;
* Elbow;
* Forearm;
* Wrist; and
* Hand
4. Lower extremity (either left or right) is recognized as the following eight distinct regions: * Hip;
* Thigh;
* Knee;
* Calf;
* Ankle; and
* Foot
C.Tests and Measurements1. When two or more procedures from 95831 through 95852 are performed on the same day, reimbursement may not exceed the lesser of the billed amount or the MAR for procedure code 95834 - Total evaluation of body, including hands.2. Functional capacity evaluation (FCE) must have pre-authorization from the payer before scheduling the tests.3. Reimbursement for extremity testing, muscle testing, and range of motion measurements (95831, 95832, 95833, 95834, 95851, 95852) will not be made more than once in a thirty (30) day period for the same body area.D.Fabrication of Orthotics1. Procedure code 97760 must be billed for the professional services of a physician or therapist to fabricate orthotics.2. Orthotics, prosthetics, and related supplies used may be billed under the appropriate HCPCS code. The maximum reimbursement allowance is listed in the HCPCS section of the Fee Schedule. For orthotics and supplies not listed in the DME section, use CPT code 99070. Reimbursement may not exceed a twenty percent (20%) mark-up of the provider's cost and an invoice may be required by the payer before reimbursement is made for items without an allowable amount in the Fee Schedule.E.Re-evaluation of an Established Patient A physician, physical therapist, occupational therapist, or speech therapist may charge and be reimbursed for a re-evaluation for therapeutic services only if new symptoms present the need for re-examination and evaluation as follows:
1. There is a definitive change in the patient's condition;2. The patient fails to respond to treatment and there is a need to change the treatment plan; and3. The patient has completed the therapy regimen and is ready to receive discharge instructions.