Effective Date: November 15, 2020
Last Updated: July 25, 2021

Purpose:
This policy provides professional reimbursement guidelines for the billing and reimbursement of therapy services. This policy applies to outpatient therapy services only.

Scope:
Products included:

• NJ FamilyCare/Medicaid
• Fully Integrated Dual Eligible Special Needs Program (FIDE-SNP)

Policy:
Horizon NJ Health will reimburse providers for one (1) therapy procedure code per member, per date of service, for each therapy discipline (i.e., physical therapy, occupational therapy, and/or speech therapy). Regardless if multiple therapy modalities are provided to the member on a given day within each discipline, only one (1) code will be reimbursed.

Additionally, for each discipline, Horizon NJ Health will not pay providers for any therapy performed on the same date of service as an evaluation within the same discipline. Therapy services billed on the same day as an evaluation shall be denied, regardless if there is a modifier appended to the evaluation code.

Documentation must support the treatment being performed as well as total timed code therapy minutes and total therapy time in minutes. Total therapy time includes the minutes for timed code therapy and untimed code therapy. Total therapy time does not include time for services that are not billable (e.g., rest periods).

For timed therapy codes, when a procedure/service indicates time, more than half of the designated time must be spent performing the service in order for a unit to be billed. In the case of a fifteen (15) minute service, at least eight (8) minutes must be performed. Any fifteen (15) minute increment timed modality rendered for less than eight (8) minutes should not be billed. Should a claim be submitted for time less than eight (8) minutes, the service shall deny.

Horizon NJ Health will deny speech-language, occupational, or physical therapy services when billed with modifier -GN, -GO or -GP in any combination on the same service line for facility claims.

Resources:
CMS Internet Only Manual, Publication 100-04, Claims Processing Manual, Chapter 5, Section 20 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf

CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 2121 “Reporting of Service Units With HCPCS”
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2121CP.pdf

CMS Manual System, Pub 100-04 Medicare Claims Processing, Transmittal 3936 “Updated Editing of Always Therapy Services – MCS”
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3936CP.pdf

American Medical Association, Current Procedural Terminology (CPT®) and associated publications and services

Limitations and Exclusions:
Notwithstanding the foregoing, all payment determinations are subject to all other, applicable limitations, including but not limited to, the following:

• Benefit Limitations;
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

History: