Therapy centers may include licensed physical therapists, occupational therapists and speech-language pathologists. Therapy providers may only render those services within the scope of their license.
• Place of service ‘11’
Revenue Codes
• Occupational Therapy
o 0434 – evaluation/re-evaluation
o 0431 – visit charge
• Physical Therapy
o 0424 - evaluation/re-evaluation
o 0421 - visit charge
• Speech Therapy
o 0444 - evaluation/re-evaluation
o 0441 - visit charge
Appropriate therapy codes and specific DME codes as listed in negotiated fee schedule.
Physical Therapists/Occupational Therapists/ Speech-Language Pathologists
Physical and occupational therapy are provided for the purpose of restoring the functional needs of a patient suffering from physical impairment due to disease, trauma or prior therapeutic intervention. Physical therapy is the treatment of disease or injury by the use of therapeutic exercise and other interventions that focus on improving or restoring posture, ambulation, strength, endurance, balance, coordination, joint mobility, flexibility, and ability to perform the functional activities of daily living and alleviating pain. Treatment comprises the use of the therapeutic proprieties of exercise, heat, cold, ultraviolet, electricity, and/or massage.
Occupational therapy (OT) is a prescribed program of treatment consisting of specific therapeutic and goal-directed activities to restore or improve skills needed to perform activities of daily living. Individual programs are designed to restore or improve the ability to conduct basic activities such as dressing, eating, personal hygiene and mobility/transfers. OT is generally focused on therapeutic activities intended to restore or improve function to the shoulder, elbow, wrist or hand. Speech therapy is the treatment of communication impairment and swallowing disorders. Speech therapy services aid in the development and maintenance of human communication and swallowing through assessment, diagnosis and rehabilitation. Autism Services -Licensed physical therapists, occupational therapists, speech-language pathologists and behavioral analysts may render autism services to applicable members in accordance with the Autism Mandate (Florida Statutes 627.6686 and 641.31098). Check eligibility and benefits to verify if a member is eligible. Refer to the Medical Policies (Medical Coverage Guidelines) for additional information.
Billing Requirements
Therapy providers may only render those services within the scope of their license.
Place of service ‘11’
Physical & Occupational Therapy Re-evaluation Billing Guidelines
Blue Cross’ standard for billing physical or occupational therapy evaluations allows a patient an initial therapy evaluation. However, a re-evaluation is covered once every three months. Should the patient’s diagnosis significantly change, the re-evaluation can be allowed sooner than the standard three-month waiting period.
Rural Health Clinic and Federally Qualified Health Clinic Billing Guidelines
Blue Cross and Blue Shield of Louisiana defines a rural health clinic (RHC) as a medical clinic located in a rural (not urban) area for the purpose of providing healthcare services to persons in the rural area.
The purpose is to service an area that does not otherwise have healthcare services available (medically underserved area). RHCs may be a primary care practice (offers at least one of the following: family practice, general practice, internal medicine or pediatric services).
Blue Cross defines a federally qualified health clinic (FQHC) as a medical clinic located in a rural or urban area for the purpose of providing healthcare services to persons who are not otherwise eligible for healthcare coverage and/or in a medically underserved area. FQHCs must provide primary care for all life-cycle ages; therefore specialty practices such as pediatric- or geriatric-only clinics are not eligible for FQHC status.
Effective January 1, 2015, we require that each healthcare professional associated with a RHC or FQHC be individually credentialed, allowing us to identify each provider in our directories. Claims should be reported based on the services provided by each individual healthcare professional within the clinic.
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