Physical and Occupational Therapy Billing Manual

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Provider Qualifications

Providers must be enrolled as a Health First Colorado (Colorado's Medicaid Program) provider in order to:

  • Treat a Health First Colorado member
  • Submit claims for payment to Health First Colorado

Licensed physical therapists (PTs) and registered occupational therapists (OTs) who meet the qualifications prescribed by federal regulations for participation at 42 CFR 484.4 and who meet all the requirements under state law are eligible to become Colorado Medical Assistance providers.

Physical therapists must be licensed by the Colorado Department of Regulatory Agencies (DORA) pursuant to Title 12 Article 41.106 and may supervise up to four individuals at one time who are not physical therapists, including certified nurse aides, to assist in the therapist's clinical practice. Supervision authority extends to the limits stated in the Physical Therapists Practice Act per section C.R.S. §12-41-113(1).

Physical therapist assistants (PTA) must be certified by DORA pursuant to Title 12 Article and must work under the supervision of a licensed physical therapist as defined in the Colorado Physical Therapy Practice Act (§12-41-203(2) C.R.S.) and accompanying rules as promulgated by the State Board of Physical Therapy.

  • PTAs cannot enroll with Health First Colorado and cannot place any identifying number on a claim form. Therefore, the supervising therapist's NPI number must be used as the rendering provider number on the claim form for services rendered by the assistant. Medical records must still indicate the assistant performed the services.

Occupational therapists must be registered by DORA pursuant to Title 12 Article 40.5.

Occupational therapy assistants (OTA) must practice under the general supervision of a Colorado registered occupational therapist.

  • OTAs cannot enroll with Health First Colorado and cannot place any identifying number on a claim form. Therefore, the supervising therapist's NPI number must be used as the rendering provider number on the claim form for services rendered by the assistant. Medical records must still indicate the assistant performed the services.

Therapy may also be rendered by licensed and enrolled physicians, physician assistants, and advanced practice nurses as allowed by their respective scopes of practice.

All providers must submit a completed provider enrollment to become a Health First Colorado provider. Providers will find enrollment information on the Provider Revalidation & Enrollment web page.

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General Benefit Policies

Physical and occupational therapists not employed by an agency, clinic, hospital, or physician may bill Health First Colorado directly, otherwise it is the employer who bills directly for the services. Providers should refer to the Code of Colorado Regulations, Qualified Non-Physician Practitioners Eligible to Provide Physician's Services (10 CCR 2505-10, Section 8.200.2.C), for further regulatory information when providing physical and occupational therapy.

  1. All PT/OT services must have a written order, referral, or prescription by any of the following:
    1. Physician (M.D. or D.O.)
    2. Physician's assistant
    3. Nurse practitioner
    4. An approved Individualized Family Service Plan (IFSP) for Early Intervention PT/OT
  2. Pursuant to the Affordable Care Act's requirements that State Medicaid Agencies ensure correct ordering, prescribing, and referring (OPR) National Provider Identification (NPI) numbers be on the claim form (42 CFR §455.440):
    1. All Outpatient PT/OT claims must contain the valid NPI number of the OPR physician, physician assistant, nurse practitioner, or provider associated with an Individualized Family Service Plan (IFSP), in accordance with Program Rule 8.125.8.A.
      1. Community Centered Boards may have their NPI listed as the referring NPI for IFSP-ordered early intervention services.
    2. All physicians, physician assistants, nurse practitioners, or providers associated with an IFSP who order, prescribe, or refer Outpatient PT/OT services for Medicaid members must be enrolled in Health First Colorado (42 CFR §455.410), in accordance with Program Rule 8.125.7.D. OPR Providers can begin enrollment on Health First Colorado's website.
      1. The new enrollment requirement for OPR providers does not include a requirement to see Medicaid members or to be listed as a Medicaid provider for patient assignments or referrals.
      2. Physicians or other eligible professionals who are already enrolled in Health First Colorado as participating providers and who submit claims to Health First Colorado are not required to enroll separately as OPR providers.
    3. Field 17.b on the CMS1500 claim form must be used for the OPR NPI number.
  3. The term "valid OPR NPI number" means the registered NPI number of the provider that legitimately orders, prescribes, or refers the Outpatient PT/OT service being rendered, as indicated by the procedure code on the claim.
    1. Claims without a valid OPR NPI number which are paid will then be subject to recovery.
    2. Medical documentation must be kept on file to substantiate the order, prescription, or referral for Outpatient PT/OT. Claims lacking such documentation on file will be subject to recovery.
  4. Health First Colorado recognizes that Outpatient PT/OT ordered in conjunction with an approved IFSP for Early Intervention may not necessarily have an ordering provider. Under this circumstance alone the rendering provider must use their own NPI number as the OPR NPI number.
    1. Early Intervention Outpatient PT/OT claims must have modifier 'TL' attached on the procedure line item for Health First Colorado to identify that the services rendered were associated with an approved IFSP.
      1. Any claim with modifier 'TL' attached must be for a service ordered by an approved IFSP and delivered within the time span noted in the IFSP.
      2. If the OPR NPI on the claim is that of the rendering provider, and the claim does not have modifier 'TL' attached, the claim is subject to recovery.
  5. Therapies provided as part of a member's individualized education program (IEP) by a therapist in the school setting are not separately reimbursable. These services are paid for by the school district which is reimbursed by the Department. Providers may not submit claims for services performed in the school setting. Refer to the School Health Services Program web page for details.

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Payment for Covered Services

  1. If Prior Authorization Requests (PAR) for services are required, the following policy applies:
    • Technical/lack of information (LOI) denial does not mean those services are not covered. Members may not be billed for services denied for LOI.
    • Services partially approved are still considered covered services. Members may not be billed for the denied portion of the request.
    • Services totally denied for not meeting medical necessity criteria are considered non-covered services.
  2. Members who reach the initial 48-unit limit for physical and occupational therapy (PT/OT) require a PAR to obtain further coverage. Refusal, failure, or negligence by the provider to request a PAR for services beyond the first 48 units of PT/OT does not mean that those additional services are non-covered.

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Medically Necessary

Outpatient physical and occupational therapy services must be medically necessary to qualify for Health First Colorado reimbursement. Medical necessity (10 CCR 2505-10 8.076.1.8) means a Medical Assistance program good or service:

  1. Will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability. This may include a course of treatment that includes mere observation or no treatment at all. Is provided in accordance with generally accepted professional standards for health care in the United States;
  2. Is clinically appropriate in terms of type, frequency, extent, site, and duration;
  3. Is not primarily for the economic benefit of the provider or primarily for the convenience of the member, caretaker, or provider;
  4. Is delivered in the most appropriate setting(s) required by the member's condition;
  5. Is not experimental or investigational; and
  6. Is not more costly than other equally effective treatment options.

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Documentation Requirements

Rendering providers must document all evaluations, re-evaluations, services provided, member progress, attendance records, and discharge plans. All documentation must be kept in the member's records along with a copy of the referral or prescribing provider's order. Documentation must support both the medical necessity of services and the need for the level of skill provided. Rendering providers must copy the member's primary care provider (PCP), prescribing provider and/or medical home on all relevant records.

All documentation must include the following:

  1. The member's name and date of birth.
  2. The date and type of service provided to the member.
  3. The name or names and titles of the persons providing each service including assistants and the name and title of the therapist supervising or directing the services.

Health First Colorado requires the following types of documentation as a record of services provided within an episode of care: initial evaluation, re-evaluation, visit/encounter notes and a discharge summary.

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Initial Evaluation
Written documentation of the initial evaluation must include the following:

  1. Referral Information: Reason for referral and referral source.
  2. History: Must include diagnoses pertinent to the reason for referral, including date of onset; cognitive, emotional, and/or physical loss necessitating referral, and the date of onset, if different from the onset of the relevant diagnoses; current functional limitation or disability as a result of the above loss, and the onset of the disability; pre-morbid functional status, including any pre-existing loss or disabilities; review of available test results; review of previous therapies/interventions for the presenting diagnoses, and the functional changes (or lack thereof) as a result of previous therapies or interventions.
  3. Assessment: The assessment section must include a summary of the member's impairments, functional limitations and disabilities, based on a synthesis of all data/findings gathered from the evaluation procedures. Pertinent factors which influence the treatment diagnosis and prognosis must be highlighted, and the inter-relationship between the diagnoses and disabilities for which the referral was made must be discussed.
  4. Plan of Care: A detailed Plan of Care must be included in the documentation of an initial evaluation. This care plan must include the following:
    1. Specific treatment goals for the entire episode of care which are functionally-based and objectively measured
    2. Proposed interventions/treatments to be provided during the episode of care
    3. Proposed duration and frequency of services to be provided
    4. Estimated duration of episode of care.
  • An episode of outpatient therapy is defined as the period of time from the first day the member is under the care of the clinician for the current condition(s) being treated by one therapy discipline until the last date of service for that plan of care for that discipline in that setting.
  • The therapist's plan of care must be reviewed, revised if necessary, and signed, as medically necessary by the member's physician, or other licensed practitioner of the healing arts within the practitioner's scope of practice under state law at least once every 90 days.
  • The care plan may not cover more than a 90-day period, or the time frame documented in the approved IFSP.
  • A plan of care must be certified. Certification is the physician's, physician's assistant or nurse practitioner's approval of the plan of care. Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. If the service is a Medicare-covered service and is provided to a member who is eligible for Medicare, the plan of care must be reviewed at the intervals required by Medicare.

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Re-Evaluation
A re-evaluation must occur whenever there is an unanticipated change in the member's status, a failure to respond to interventions as expected or there is a need for a new plan of care based on new problems and goals requiring significant modification of treatment plan. The documentation for a re-evaluation need not be as comprehensive as the initial evaluation, but must include at least the following:

  1. Reason for re-evaluation
  2. Member's health and functional status reflecting any changes
  3. Findings from any repeated or new examination elements
  4. Changes to plan of care

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Visit/Encounter Notes
Written documentation of each encounter must be in the member's record of service. These visit notes document the implementation of the plan of care established by the therapist at the initial evaluation. Each visit note must include the following:

  1. The member's name and date of birth.
  2. The date of service.
  3. The type of service provided to the member.
  4. Total timed code treatment minutes and total treatment time in minutes.
    1. Total treatment time includes the minutes for timed code treatment and untimed code treatment.
    2. Total treatment time does not include time for services that are not billable (e.g., rest periods).
    3. The time spent providing each service. The number of units billed/requested must match the documentation (billing and the total timed code treatment minutes must be consistent).
  5. A description of each service provided during the encounter including procedure codes. The description should support each procedure code billed.
  6. The name or names and titles of the persons providing each service including assistants and the name and title of the therapist supervising or directing the services.
  7. Identification of the short or long-term goals being addressed during the encounter.

In addition to the above required information items, the visit note documentation must contain the Subjective, Objective, Assessment and Plan format elements. These may be documented in any order (i.e. SOAP, APSO, etc.)

  1. A subjective element which includes the reason for the visit, the member/caregiver's report of current status relative to treatment goals, and any changes in member's status since the last visit;
  2. An objective element which includes the practitioner's findings, including abnormal and pertinent normal findings from any procedures or tests performed;
  3. An assessment component which includes the practitioner's assessment of the member's response to interventions provided, specific progress made toward treatment goals, and any factors affecting the intervention or progression of goals, and
  4. A plan component that states the plan for the next visit(s).

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Discharge Summary
At the conclusion of therapy services, a discharge summary must be included in the documentation of the final visit in an episode of care. This must include the following:

  1. Highlights of a member's progress or lack of progress towards treatment goals.
  2. Summary of the outcome of services provided during the episode of care.

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Covered Services

Physical and Occupational Therapy services are covered if they are medically necessary as defined in 10 CCR 2505-10 Section 8.076.1.8 and meet the following criteria:

  1. Treatment services must be ordered by an eligible prescribing provider (Physician, Physician Assistant, or Advanced Practice Nurse), and be started within 28 days of the date ordered.
  2. Therapy services must be provided under a written treatment plan stating with specificity the member's condition, functional level, treatment objectives, the physicians order, plans for continuing care, modifications to the plan, and the plans for discharge from treatment.
  3. In a manner consistent with accepted standards of medical practice, the service is found to be equally effective for a diagnosis or treatment compared to other less conservative or more costly treatment options.
  4. The service has a base of evidence (including peer-reviewed literature and/or clinical experience and judgment) to support the clinical reasoning and selection of interventions.
  5. The service is consistent with the member's confirmed diagnosis, and not in excess of the member's needs.

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Non-Covered Services

  1. A member may receive outpatient physical therapy and occupational therapy services during the same period and service dates; however, duplicate therapy (the same therapy performed by both an OT and PT) may not be performed on the same dates of service. Duplicated services (in general, and those overlapped between PTs and OTs) are not covered.
  2. Art and craft activities for the purposes of recreation are not covered.
  3. Hippotherapy/equine therapy is not covered.
  4. Services that are experimental, investigational, or are provided as part of a clinical trial are not covered.
  5. Supplies or pre-fabricated supplies that can be obtained from a medical supplier are not covered.
  6. Services for conditions of chronic pain that do not interfere with the member's functional status and that can be treated by routine nursing measures are not covered.
  7. Services not documented in the member's health care record are not covered.
  8. Services not part of the member's plan of care are not covered.
  9. Services specified in a plan of care that is not reviewed and revised as medically necessary by the member's physician (M.D. or D.O.), physician's assistant, nurse practitioner, or specified in an approved Individualized Family Service Plan (IFSP) for Early Intervention PT/OT are not covered.
  10. A therapeutic service that is denied Medicare payment because of the provider's failure to comply with Medicare requirements is not covered.
  11. Vocational or educational services, except as provided under IEP-related or waiver services are not covered.
  12. Psychosocial services are not covered.
  13. Educational, personal need and comfort therapies are not covered.
  14. Record keeping documentation and travel time (the transport and waiting time of a member to and from therapy sessions) is not reimbursable.
  15. Time spent for preparation, report writing, processing of claims, or documentation regarding billing or service provision is not reimbursable.

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Specific Non-Covered Modalities

All treatment modalities must meet the medical necessity standard. See 10 C.C.R. 2505-10, § 8.076.1.8. The following modalities are not covered under the occupational therapy benefit for Health First Colorado due to not meeting the medical necessity standard.

  1. Eye Movement Desensitization and Reprocessing
  2. Relationship Development Intervention
  3. Internal Family Systems

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Rehabilitative and Habilitative Therapy Definitions

Health First Colorado covers both rehabilitative and habilitative therapies for all age groups in accordance with the Affordable Care Act Essential Health Benefit provisions.

The Colorado Division of Insurance defined Habilitative services to be:

Services that help a person retain, learn, or improve skills and functioning for daily living that are offered in parity with, and in addition to, any rehabilitative services offered in Colorado's Essential Health Benefits benchmark plan. Parity in this context means of like type and substantially equivalent in scope, amount, and duration.

Rehabilitative therapies are those meant to assist a member with recovery from an acute injury, illness, or surgical recovery. Habilitative therapies are those meant to help the member retain, learn, or improve skills and functions for daily living. This includes the treatment of long-term chronic conditions and meeting developmental milestones.

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Additional Notes

  • Habilitative therapies are not categorized as an Inpatient or Home Health benefit. 'Acute' and 'Long-term' therapies remain benefits per Home Health coverage.
  • Habilitative therapies are not a benefit if provided in nursing facilities; Rehabilitative PT/OT remain benefits in that setting.
  • Habilitative therapies should not to be confused with Habilitation services found within Home and Community Based Services (HCBS) waivers

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Assistive Technology Assessments

The following billing policies are effective for CPT procedure code 97755 to accommodate HB14- 1211. HB14-1211 requires that all Medicaid members seeking complex rehabilitation technology must have an initial Assistive Technology Assessment (complex rehabilitative technology evaluation/assessment) prior to receiving complex rehabilitation technology, and follow-up assessments, as needed. Only licensed speech, physical, and occupational therapists may render this specialty evaluation. All providers using procedure code 97755 must follow these guidelines. The Department recognizes that only a portion of Assistive Technology Assessments will be used for complex rehabilitation technology evaluation/assessment. Providers will be asked upon PAR submission if the service is for a complex rehabilitation technology assessment.

Policy Notes
Complex rehabilitation technology evaluations / assessments are billed using only 97755. Combinations of procedure codes, including procedure code 97542, for the purposes of complex rehabilitation technology evaluation / assessment are not allowed.
97755 always requires a Prior Authorization Request (PAR). PARs must be submitted electronically using ColoradoPAR. Details are found on the ColoradoPAR website.
Member daily limit of 97755 is 20 units. Up to five hours of assessment is allowed per date of service.
Member yearly limit of 97755 is 60 units. Members may have up to 60 units of procedure code 97755 per State Fiscal Year (July 1 – June 30). This limit will reset with the start of each new State Fiscal Year.

PARs for 97755 must comply with the following policies:

  1. Must have a current prescription/referral for an Assistive Technology Assessment from the member's primary care physician.
  2. May indicate up to one-year duration.
  3. May indicate initial/new assessments or follow-up assessment visits.
  4. Only one active PAR for 97755 is allowed per member, per span of time. Overlapping 97755 PAR requests will be denied.
  5. Initial PT/OT evaluation services, such as 97161, are not required prior to requesting 97755.
  6. 97755 is separate from PT/OT and is not part of the PT/OT benefit limitation.
  7. PARs for 97755 should be submitted independently from other services. The Medical PAR type should be selected for 97755 at ColoradoPAR.com.

If a member requires further assessment by a different provider not indicated on the original PAR, and that PAR is still active, then it must be closed by the original requesting provider. Once closed a new PAR can be submitted. Members may request a 'change of provider' on their PAR by contacting the vender directly. Please see the Prior Authorization Request section of this manual.

Benefit Limitations

  1. A daily limit of five units of physical therapy services and five units of occupational therapy services is allowed, whether it is rehabilitative or habilitative. Some specific daily limits per procedure code apply.
    1. Providers are required to consult the American Medical Association's (AMA) Current Procedural Terminology (CPT) manual for each coded service. Some codes represent a treatment session without regard to its length of time (one unit maximum) while other codes may be billed incrementally as "timed" units.
  2. Members may receive up to 48 units of any combination of PT/OT services per rolling 12-month period before a Prior Authorization Request (PAR) is required. Evaluation and orthotic services are not included in this limit. This equates to roughly 12 hours of therapy services (each unit of service being equal to 15 minutes). This unit limit will be automatically enforced by the claims payment system by denying claims that exceed the limit.
  3. Units of service exceeding the initial 48 units are not covered without an approved PAR.
  4. The 12-month period begins when therapy is initiated. The unit limit does not roll-over to accumulate more than 48 available units in a 12-month period. Units are continually available until the limit of 48 has been reached in a 12-month period.
  5. Units decrement from paid units for a specific member, regardless of provider, beginning on the first date of service. A unit equals either 1) a timed increment or 2) one treatment session as described in the specific CPT procedure codes.

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National Correct Coding Initiative (NCCI)

National Correct Coding Initiative Procedure-To-Procedure (PTP) and Medically Unlikely Edits (MUE) edits apply to certain combinations of PT and OT procedure codes. Please refer to the Medicaid website for NCCI edits, for a complete list of impacted codes, guidance on bypass modifier use, and general information.

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Coding Tables

Eligible Place of Service Codes

The following place of service codes are allowed:

Place of Service (POS) code Description
02 Telemedicine (only applicable to certain procedure codes, see details below)
11 Office
12 Home
13 Assisted Living Facility
62 Comprehensive Outpatient Rehabilitation Facility
99 Other – community location
  • Telemedicine place of service (POS) code 02 is available for specific procedure codes. See the Telemedicine - Provider Information web page for a list of allowed procedure codes.
  • Therapy services provided at an Outpatient Hospital are reported on the institutional claim type and are reimbursed as part of the hospital's EAPG payment. Institutional claim types do not have the POS code field.
  • Therapy services provided at a Federally Qualified Health Center (FQHC) and Rural Health Clinic (RHC) are billed as part of the encounter rate for the center. They must not be billed separately on professional claims.
  • POS code '99' is used for community locations (such as a library or grocery store) where services took place which are not better described as 'home', which is for the member's place of residence.
  • Early Intervention providers may report any POS code which aligns with the treatment ordered by the child’s Individualized Family Service Plan.  
Outpatient Therapy Type Modifier 1 Modifier 2
Rehabilitative Physical Therapy GP 97
Rehabilitative Occupational Therapy GO 97
 
Habilitative Physical Therapy GP 96
Habilitative Occupational Therapy GO 96
 
Early Intervention Physical Therapy GP TL
Early Intervention Occupational Therapy GO TL

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Eligible Outpatient PT/OT Procedure Codes

Physical and Occupational Therapists are indicated as rendering providers for the following procedures. Reference the current Fee Schedule for rates. Evaluation and orthotic services are not subject to the 48-unit limit.

  • This table serves only as a reference guide and not a guarantee of payment or coverage. Definitive coverage of a specific procedure code is found on the Fee Schedule.
  • Report procedure codes 97001, 97002, 97003, 97004 for evaluation services performed prior to 12/31/2016. Report procedure codes 97161-97168 for evaluation services performed on/after 1/1/2017.
  • NCCI MUE edits stipulate maximum daily units for each code. Reference the NCCI website for further information.
  • Providers should reference official AMA CPT resources for full descriptions of codes and instruction for proper use.

Table updated: August 2019

Procedure Code Provider Type Prior Authorization Required Comments
92526 OT Always  
90911 PT No  
96112 PT, OT No  
96113 PT, OT No  
97010 PT, OT Sometimes  
97012 PT, OT Sometimes  
97014 PT, OT Sometimes  
97016 PT, OT Sometimes  
97018 PT, OT Sometimes  
97022 PT, OT Sometimes  
97024 PT, OT Sometimes  
97026 PT, OT Sometimes  
97028 PT, OT Sometimes  
97032 PT, OT Sometimes  
97033 PT, OT Sometimes  
97034 PT, OT Sometimes  
97035 PT, OT Sometimes  
97036 PT, OT Sometimes  
97110 PT, OT Sometimes  
97112 PT, OT Sometimes  
97113 PT, OT Sometimes  
97116 PT, OT Sometimes  
97124 PT, OT Sometimes  
97127 - - Not Covered. See G0515.
97129 PT, OT Always Effective 1/1/2020
97130 PT, OT Always Effective 1/1/2020
97140 PT, OT Sometimes  
97150 PT, OT Sometimes  
97161 PT No  
97162 PT No  
97163 PT No  
97164 PT No  
97165 OT No  
97166 OT No  
97167 OT No  
97168 OT No  
97530 PT, OT Sometimes  
G0515 PT, OT Sometimes Closed 12/31/2019
97533 PT, OT Sometimes  
97535 PT, OT Sometimes  
97537 PT, OT Sometimes  
97542 PT, OT Sometimes  
97545 PT, OT Sometimes  
97546 PT, OT Sometimes  
97597 PT, OT No  
97598 PT, OT No  
97602 PT, OT No  
97750 PT, OT No  
97755 PT, OT Always Modifiers 96 or 97 are not required for this procedure code as this evaluation cannot be classified as either ‘rehabilitative’ or ‘habilitative’. 
97760 PT, OT No  
97761 PT, OT Sometimes  
97763 PT, OT No  
97799 PT, OT Sometimes Functional Dry Needling is reported using CPT 97799 until the provider transitions to using 20560/20561 in 2020. Claims require attachments with documentation and will be manually reviewed.
20560 PT Always Effective 1/1/2020
20561 PT Always Effective 1/1/2020
L1902 PT, OT No  
L1960 PT, OT No  
L3730 PT, OT No  
L3763 PT, OT No  
L3764 PT, OT No  
L3808 PT, OT No  
L3900 PT, OT No  
L3906 PT, OT No  
L3908 PT, OT No  
L3912 PT, OT No  
L3919 PT, OT No  
L3923 PT, OT No  
L3925 PT, OT No  
L3929 PT, OT No  
L3933 PT, OT No  
L3982 PT, OT No  
Q4040 PT, OT No  
Q4048 PT, OT No  

 

For further billing information on the above orthotic/prosthetic codes, please refer to the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) provider billing manual, available on the Billing Manuals web page.

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Reporting of Service Units

A. Timed and Untimed Codes

When reporting service units for CPT/HCPCS codes where the procedure is not defined by a specific timeframe ("untimed" CPT/HCPCS), the provider enters "1" in the field labeled "units." For untimed codes, units are reported based on the number of times the procedure is performed, as described in the CPT/HCPCS code definition.

EXAMPLE: A member received a speech-language pathology evaluation represented by HCPCS "untimed" code 92521. Regardless of the number of minutes spent providing this service, only one unit of service is appropriately billed on the same day.

Several CPT codes used for therapy modalities, procedures, tests and measurements specify that the direct (one-on-one) time spent in patient contact is 15 minutes. Providers report these "timed" procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15-minute units of service.

EXAMPLE: A member received a total of 60 minutes of occupational therapy, e.g., HCPCS "timed" code 97530 which is defined in 15-minute units, on a given date of service. The provider would then report 4 units of code 97530.

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B. Counting Minutes for Timed Codes in 15 Minute Units

When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code in the same day measured in 15-minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes, through and including 37 minutes, then 2 units should be billed. Time intervals for 1 through 8 units are as follows:

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Units Number of Minutes

 

1 unit: ≥ 8 minutes through 22 minutes
2 units: ≥ 23 minutes through 37 minutes
3 units: ≥ 38 minutes through 52 minutes
4 units: ≥ 53 minutes through 67 minutes
5 units: ≥ 68 minutes through 82 minutes
6 units: ≥ 83 minutes through 97 minutes
7 units: ≥ 98 minutes through 112 minutes
8 units: ≥ 113 minutes through 127 minutes

 

The pattern remains the same for treatment times in excess of 2 hours.

When more than one service represented by 15-minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of timed units billed. See example 1 below.

If any 15-minute timed service that is performed for 7 minutes or less than 7 minutes on the same day as another 15-minute timed service that was also performed for 7 minutes or less and the total time of the two is 8 minutes or greater than 8 minutes, then bill one unit for the service performed for the most minutes. This is correct because the total time is greater than the minimum time for one unit. The same logic is applied when three or more different services are provided for 7 minutes or less than 7 minutes. See example 5 below.

The Outpatient Physical and Occupational, and Speech Therapy Billing Manuals, Documentation Requirements section, indicates that the amount of time for each specific intervention/modality provided to the member is required to be documented in the Visits/Encounter Note. The total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units for the total therapy minutes provided.

Example 1 –

24 minutes of neuromuscular reeducation, code 97112,
23 minutes of therapeutic exercise, code 97110,
Total timed code treatment time was 47 minutes.

 

See the chart above. The 47 minutes falls within the range for 3 units = 38 to 52 minutes.

Appropriate billing for 47 minutes is only 3 timed units. Each of the codes is performed for more than 15 minutes, so each shall be billed for at least 1 unit. The correct coding is 2 units of code 97112 and one unit of code 97110, assigning more timed units to the service that took the most time.

Example 2 –

20 minutes of neuromuscular reeducation (97112)
20 minutes therapeutic exercise (97110),
40 Total timed code minutes.

 

Appropriate billing for 40 minutes is 3 units. Each service was done at least 15 minutes and should be billed for at least one unit, but the total allows 3 units. Since the time for each service is the same, choose either code for 2 units and bill the other for 1 unit. Do not bill 3 units for either one of the codes.

Example 3 –

33 minutes of therapeutic exercise (97110),
7 minutes of manual therapy (97140),
40 Total timed minutes

 

Appropriate billing for 40 minutes is for 3 units. Bill 2 units of 97110 and 1 unit of 97140. Count the first 30 minutes of 97110 as two full units. Compare the remaining time for 97110 (33-30 = 3 minutes) to the time spent on 97140 (7 minutes) and bill the larger, which is 97140.

Example 4 –

18 minutes of therapeutic exercise (97110),
13 minutes of manual therapy (97140),
10 minutes of gait training (97116),
8 minutes of ultrasound (97035),
49 Total timed minutes

 

Appropriate billing is for 3 units. Bill the procedures you spent the most time providing. Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed). You would still document the ultrasound in the treatment notes.

Example 5 –

7 minutes of neuromuscular reeducation (97112)
7 minutes therapeutic exercise (97110)
7 minutes manual therapy (97140)
21 Total timed minutes

 

Appropriate billing is for one unit. The qualified professional shall select one appropriate CPT code (97112, 97110, 97140) to bill since each unit was performed for the same amount of time and only one unit is allowed.

NOTE: The above schedule of times is intended to provide assistance in rounding time into 15-minute increments. It does not imply that any minute until the eighth should be excluded from the total count. The total minutes of active treatment counted for all 15-minute timed codes includes all direct treatment time for the timed codes. Total treatment minutes - including minutes spent providing services represented by untimed codes - are also documented.

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C. Determining What Time Counts Towards 15-Minute Timed Codes

Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted in determining the treatment service time. In other words, the time counted as "intra-service care" begins when the therapist or physician (or an assistant under the supervision of a physician or therapist) is directly working with the patient to deliver treatment services. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.

The time counted is the time the patient is treated. For example, if gait training in a patient with a recent stroke requires both a therapist and an assistant, or even two therapists, to manage in the parallel bars, each 15 minutes the patient is being treated can count as only one unit of code 97116. The time the patient spends not being treated because of the need for toileting or resting should not be billed. In addition, the time spent waiting to use a piece of equipment or for other treatment to begin is not considered treatment time.

Treatment time for untimed codes are not to be counted towards the total treatment time for 15-minute unit codes.

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Prior Authorization Requests (PARs)

Providers must submit PARs for medically necessary services when services will exceed 48 units of service per 12-month period.

PARs are approved for up to a 12-month period (depending on medical necessity determined by the reviewer).

  • Retroactive PAR request forms will not be accepted.
  • Overlapping PAR request dates for same provider types will not be accepted, with the exception of Early Intervention PAR requests which may have overlapping dates of service and multiple provider types. All Early Intervention PT/OT PARs must additionally indicate that the member has an Individual Family Service Plan (IFSP) and that it is current and approved.
  • Only one PAR for Early Intervention outpatient PT/OT may be active at a time.
  • A maximum of one PAR for Early Intervention outpatient PT/OT and one PAR for non-Early Intervention outpatient PT/OT may be active at any time for children ages 0 – 3.
  • Overlapping Early Intervention and non-Early Intervention outpatient PT/OT PARs will only be accepted if the treatment plans associated with each meet different goals and use different treatments.
  • Incomplete, incorrect or insufficient member information on a PAR request form will not be accepted.

Submit PARs for the number of units for each specific procedure code requested, not for the number of services. Modifier codes must be included. The same modifiers used on the PAR must be used on the claim, in the same order.

  • When submitting Rehabilitative Therapy PARs, and subsequent claims, CPT codes for PT services must have the GP modifier and the 97 modifier (e.g. 97110+GP+97). CPT codes for OT services must have the GO modifier and 97 modifier (e.g. 97110+GO+97).
  • When submitting Habilitative Therapy PARs, and subsequent claims, CPT codes for PT services must have the GP modifier and 96 modifier (e.g. 97110+GP+96). CPT codes for OT services must have the GO modifier and 96 modifier (e.g. 97110+GO+96).
  • Early Intervention PARs, and subsequent claims, must have the GP or GO modifier plus the TL modifier (e.g. 97110+GP+TL).

Additional Limitations:

  • Members may have one active PAR for each type of therapy (Rehabilitative PT, Rehabilitative OT, Habilitative PT, and Habilitative OT) with independent time spans. These PARs may not overlap in time span unless one of them is for Early Intervention.
  • Evaluation and orthotic services do not require a PAR.

PAR Requirements:

  • Legibly written and signed ordering practitioner prescription or approved Plan of Care, to include:
    • diagnosis (preferably with ICD-10 code), and
    • reason for therapy, and
    • the number of requested therapy sessions per week, and
    • total duration of therapy.
  • The member's Physical or Occupational treatment history, including current assessment and treatment. Include duration of previous treatment and treating diagnosis.
  • Documentation indicating if the member has received PT or OT under the Home Health Program or inpatient hospital treatment.
  • Current treatment diagnosis.
  • Course of treatment, measurable goals and reasonable expectation of completed treatment.
  • Documentation supporting medical necessity for the course and duration of treatment being requested.
  • Assessment or progress notes submitted for documentation, must not be more than 60 days prior to submission of PAR request.
  • If the PAR is submitted for services delivered by an independent therapist, the name and address of the individual therapist providing the treatment must be present in field #24 of the PAR.
  • The billing provider name and address needs to be present in field #25 on the PAR.
  • The Health First Colorado provider number of the independent therapist must be present in PAR field #28.
  • The billing provider's Health First Colorado number must be present in field #29 of the PAR.
  • Early Intervention PT/OT PARs must additionally indicate that the member has an Individual Family Service Plan (IFSP) and that it is current and approved.
  • DME products cannot be requested on the same PAR as therapy services.

The authorizing agency reviews all completed PARs and approves or denies, by individual line item, each requested service or supply listed on the PAR. PAR status inquiries can be made through the Online Provider Web Portal and results are included in PAR letters sent to both the provider and the member. Read the results carefully as some line items may be approved and others denied. Do not render or bill for services until the PAR has been processed.

The claim must contain the PAR number for reimbursement. If the PAR is denied, providers should direct inquiries to the authorizing agency, which can be found on the Provider Contacts web page.

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Billing Information

Refer to the General Provider Information manual for general billing information.

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Billing Edits

The provider's adherence to the application of policies in this manual is monitored through either post-payment review of claims by the Department, or computer audits or edits of claims. When computer audits or edits fail to function properly, the application of policies in this manual remain in effect. Therefore, all claims shall be subject to review by the Department.

 

Occupational Therapy PAR Form Example

Occupational Therapy PAR Form Example

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Patient's Relationship to Insured Conditional Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070117 for July 1, 2017.

Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Conditional Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician or other source Not Required  
17.b. NPI of Referring Physician or other source Required Per Program Rule 8.125.8, all outpatient physical and occupational therapy services require a referring provider NPI.

Services rendered in accordance with an ISFP may not always have a referring physician. In this circumstance alone, the rendering provider's NPI must be entered in this field.
18. Hospitalization Dates Related to Current Service Conditional Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two digits for the month, two digits for the date and two digits for the year. Example: 070118 for July 1, 2018. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.
19. Additional Claim Information Not Required  
20. Outside Lab?
$ Charges
Conditional Complete if all laboratory work was referred to and performed by an outside laboratory. If this box is checked, no payment will be made to the physician for lab services. Do not complete this field if any laboratory work was performed in the office.

Practitioners may not request payment for services performed by an independent or hospital laboratory.
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional CLIA
When applicable, enter the word "CLIA" followed by the number.

Prior Authorization
Enter the six-character prior authorization number from the approved Prior Authorization Request (PAR). Do not combine services from more than one approved PAR on a single claim form. Do not attach a copy of the approved PAR unless advised to do so by the authorizing agent or the fiscal agent.
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Single Date of Service: Enter the six digit date of service in the "From" field. Completion of the "To field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information.
ZZ - Narrative description of unspecified code
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.

See manual's section on eligible place of service code
24C. EMG Conditional Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-pay requirements.
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Conditional Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

See manual's section on required billing modifiers
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.

Anesthesia Services
Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period.

Anesthesia time begins when the anesthetist begins member preparation for induction in the operating room or an equivalent area and ends when the anesthetist is no longer in constant attendance. No additional benefit or additional units are added for emergency conditions or the member's physical status.

The fiscal agent converts reported anesthesia time into fifteen minute units. Any fractional unit of service is rounded up to the next fifteen minute increment.

Codes that define units as inclusive numbers
Some services such as allergy testing define units by the number of services as an inclusive number, not as additional services.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV - Available- Not Used
S2 - Under Treatment
ST - New Service Requested
NU - Not Used

Family Planning (unshaded area)
If the service is Family Planning, enter "Y" for YES or "N" for NO in the bottom unshaded portion of the field.
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider's name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
"Signature on file" notation is not acceptable in place of an authorized signature.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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CMS 1500 OT/PT Claim Example

CMS 1500 OT/PT Claim Examples

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UB-04 Paper Claim Reference Table

PT and OT outpatient hospital paper claims must be submitted on the UB-04 claim form.

The information in the following Paper Claim Reference Table lists the required, optional and/or conditional form locators for submitting the UB-04 paper claim form to Health First Colorado for PT and OT services. It also provides instructions for completing Form Locators (FL) as they appear on the paper UB-04 claim form. Instructions for completing the UB-04 claim form are based on the current National Uniform Billing Committee (NUBC) UB-04 Reference Manual. Unless otherwise noted, all data FLs on the UB-04 have the same attributes (specifications) for Health First Colorado as those indicated in the NUBC UB-04 Reference Manual.

All code values listed in the NUBC UB-04 Reference Manual for each FL may not be used for submitting paper claims to Health First Colorado. The appropriate code values listed in this manual must be used when billing Health First Colorado.

Form Locator and Labels Completion Format Instructions
1. Billing Provider Name, Address, Telephone Number Text Required
Enter the provider or agency name and complete mailing address of the provider who is billing for the services:
  • Street
  • City
  • State
  • Zip Code
Abbreviate the state using standard post office abbreviations. Enter the telephone number.
2. Pay-to Name, Address, City, State Text Required only if different from FL 1.
Enter the provider or agency name and complete mailing address of the provider who will receive payment for the services:
  • Street/Post Office box City
  • State Zip Code
  • Abbreviate the state using standard post office abbreviations. Enter the telephone number.
3a. Patient Control Number Up to 20 characters: Letters, numbers or hyphens Optional
Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
3b. Medical Record Number 17 digits Optional
Enter the number assigned to the member to assist in retrieval of medical records.
4. Type of Bill 3 digits Required
For PRTF, use TOB 89X.
Enter the three-digit number indicating the specific type of bill. The three-digit code requires one digit each in the following sequences (Type of facility, Bill classification, and Frequency):
Digit 1 Type of Facility
1 Hospital
2 Skilled Nursing
3 Home Health Services
4 Religious Non-Medical Health Care Institution
6 Intermediate Care
7 Clinic (Rural Health/FQHC/Dialysis Center)
8 Special Facility (Hospice, RTCs)
Digit 2 Bill Classification (Except clinics & special facilities):
1 Inpatient (Including Medicare Part A)
2 Inpatient (Medicare Part B only)
3 Outpatient
4 Other (for hospital referenced diagnostic services or home health not under a plan of treatment)
5 Intermediate Care Level I
6 Intermediate Care Level II
7 Sub-Acute Inpatient (Revenue Code 019X required with this bill type)
8 Swing Beds
9 Other
Digit 2 Bill Classification (Clinics Only):
1 Rural Health/FQHC
2 Hospital Based or Independent Renal Dialysis Center
3 Freestanding
4 Outpatient Rehabilitation Facility (ORF)
5 Comprehensive Outpatient Rehabilitation Facilities (CORFs)
6 Community Mental Health Center
Digit 2 Bill Classification (Special Facilities Only):
1 Hospice (Non-Hospital Based)
2 Hospice (Hospital Based)
3 Ambulatory Surgery Center
4 Freestanding Birthing Center
5 Critical Access Hospital
6 Residential Facility
Digit 3 Frequency:
0 Non-Payment/Zero Claim
1 Admit through discharge claim
2 Interim - First claim
3 Interim - Continuous claim
4 Interim - Last claim
7 Replacement of prior claim
8 Void of prior claim
5. Federal Tax Number None Submitted information is not entered into the claim processing system.
6. Statement covers period From/Through From:6 digits MMDDYY
Through: 6 digits MMDDYY
Required
(Note: OP claims cannot span over a month's end)

Enter the From (beginning) date and Through (ending) date of service covered by this bill using MMDDYY format. Example: January 1, 2016 = 0101016

This form locator must reflect the beginning and ending dates of service. When span billing for multiple dates of service and multiple procedures, complete FL 45 (Service Date). Providers not wishing to span bill following these guidelines, must submit one claim per date of service. "From" and "Through" dates must be the same. All line item entries must represent the same date of service.
8a. Patient Identifier Text Not Required
Submitted information is not entered into the claim processing system.
8b. Patient Name Up to 25 characters; letters & spaces Required
Enter the member's last name, first name and middle initial.
9a. Patient Address – Street Characters Letters & numbers Required
Enter the member's street/post office box as determined at the time of admission.
9b. Patient Address – City Text Required
Enter the member's city as determined at the time of admission
9c. Patient Address – State Text Required
Enter the member's state as determined at the time of admission.
9d. Patient Address – ZIP Digits Required
Enter the member's zip code as determined at the time of admission.
9e. Patient Address – Country Code Digits Optional
10. Birthdate 8 digits (MMDDCCYY) Required
Enter the member's birthdate using two digits for the month, two digits for the date, and four digits for the year (MMDDCCYY format). Example: 01012010 for January 1, 2010.
11. Patient Sex 1 letter Required
Enter an M (male) or F (female) to indicate the member's sex.
12. Admission Date 6 digits Conditional
Required for observation holding beds only
13. Admission Hour 6 digits Conditional
Required for observation holding beds only
14. Admission Type 1 digit Required
Enter the following to identify the admission priority:
1 – Emergency

Member requires immediate intervention as a result of severe, life threatening or potentially disabling conditions.

Exempts inpatient hospital & clinic claims from co-payment and PCP referral.

Exempts outpatient hospital claims from co- payment and PCP only if revenue code 450 or 459 is present.

This is the only benefit service for an undocumented alien.

If span billing, emergency services cannot be included in the span bill and must be billed separately from other outpatient services.

1- Urgent
The member requires immediate attention for the care and treatment of a physical or mental disorder.

2- Elective
The member’s condition permits adequate time to schedule the availability of accommodations.


3- Newborn
Required for inpatient and outpatient hospital.

4- Trauma Center
Visit to a trauma center/hospital as licensed or designated by the state or local government authority authorized to do so, or as verified by the American College of Surgeons and involving trauma activation.

Clinics
Required only for emergency visit.
15. Source of Admission 1 digit Required
Enter the appropriate code for co-payment exceptions on claims submitted for outpatient services. (To be used in conjunction with FL 14, Type of Admission).
1 Physician referral
2 Clinic referral
3 Referred from HMO
4 Transfer from a hospital
5 Transfer from a skilled nursing facility (SNF)
6 Transfer from another health care facility
7 Emergency Room
8 Court/Law Enforcement
9 Information not available
A Transfer from a Critical Access Hospital
B Transfer from another Home Health Agency
C Readmission to Same Home Health Agency
Newborns
1 Normal Delivery
2 Premature Delivery
3 Sick Baby
4 Extramural Birth (Birth in a non- sterile environment)
16. Discharge Hour 2 digits Not Required
Enter the hour the member was discharged from inpatient hospital care. Use the same coding used in FL 13 (Admission Hr.)
17. Patient Discharge Status 2 digits Conditional
 
01 Discharged to Home or Self Care (Dialysis is limited to code 01)
02 Discharged/transferred to another short-term hospital
70 Discharged/Transferred to Other HC Institution
71 Discharged/transferred/referred to another institution for outpatient services
72 Discharged/transferred/referred to this institution for outpatient services
Use code 02 for a PPS hospital transferring a
patient to another PPS hospital.
Code 05, Discharged to Another Type Institution, is the most appropriate code to use for a PPS hospital transferring a patient to an exempt hospital.

**A PPS hospital cannot use Patient Status codes 30, 31 or 32 on any claim submitted for DRG reimbursement. The code(s) are valid for use on exempt hospital claims only.

Interim bills may be submitted for Prospective Payment System (PPS)-DRG claims but must meet specific billing requirements.

For exempt hospitals use the appropriate code from the codes listed. Note: Refer to the "Interim" billing instruction in this section of the manual.
18-28. Conditions Codes 2 digits Conditional

Complete with as many codes necessary to identify conditions related to this bill.

Condition Codes
01 Military service related 02 Employment related 04 HMO enrollee 05 Lien has been filed 06 ESRD patient - First 18 months entitlement 07 Treatment of non-terminal condition/hospice patient 17 Patient is homeless 25 Patient is a non-US resident 39 Private room medically necessary 42 Outpatient Continued Care not related to Inpatient 44 Inpatient CHANGED TO Outpatient 51 Outpatient Non-diagnostic Service unrelated to Inpatient admit 60 DRG (Day outlier) Renal dialysis settings
71 Full care unit
72 Self care unit
73 Self care training
74 Home care
75 Home care – 100 percent reimbursement 76 Back-up facility Special Program Indicator Codes
A1 EPSDT/CHAP
A2 Physically Handicapped Children's Program
A4 Family Planning
A6 PPV/Medicare
A9 Second Opinion Surgery
AA Abortion Due to Rape
AB Abortion Done Due to Incest
AD Abortion Due to Life Endangerment
AI Sterilization
B3 B4 Pregnancy Indicator
Admission Unrelated to Discharge PRO Approval Codes
C1 Approved as billed
C2 Automatic approval as billed - Based on focused review
C3 Partial approval
C4 Admission/Services denied
C5 Post payment review applicable
C6 Admission preauthorization
C7 Extended authorization
29. Accident State 2 digits Optional
31 – 34. Occurrence Code/Date 2 digits & 6 digits Conditional
Complete both the code and date of occurrence.
Enter the appropriate code and the date on which it occurred. Enter the date using MMDDYY format.
Occurrence Codes:
1 Accident/Medical Coverage
2 Auto Accident - No Fault Liability
3 Accident/Tort Liability
4 Accident/Employment Related
5 Other Accident/No Medical Coverage or Liability Coverage
6 Crime Victim
20 Date Guarantee of Payment Began
24* Date Insurance Denied
25* Date Benefits Terminated by Primary Payer
26 Date Skilled Nursing Facility Bed Available
27 Date of Hospice Certification or Re- certification
40 Scheduled Date of Admission (RTD)
50 Medicare Pay Date
51 Medicare Denial Date
53 no longer used
55 Insurance Pay Date
A3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer A indicated in FL 50
B3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer B indicated in FL 50
C3 Benefits Exhausted - Indicate the last date of service that benefits are available and after which payment can be made by payer C indicated in FL 50
*Other Payer occurrence codes 24 and 25 must be used when applicable. The claim must be submitted with the third-party information
35-36. Occurrence Span Code From/ Through Digits Leave blank
38. Responsible Party Name/Address None Leave blank
39 – 41. Value Codes and Amounts 2 characters and up to 9 digits Conditional
Enter appropriate codes and related dollar amounts to identify monetary data or number of days using whole numbers, necessary for the processing of this claim. Never enter negative amounts. Codes must be in ascending order. If a value code is entered, a dollar amount or numeric value related to the code must always be entered.
Most Common Codes:
01 semiprivate rate (Accommodation Rate)
06 Medicare blood deductible
14 No fault including auto/other
15 Worker's Compensation
31 Member Liability Amount*
32 Multiple Member Ambulance Transport
37 Pints of Blood Furnished
38 Blood Deductible Pints
40 New Coverage Not Implemented by HMO
45 Accident Hour
Enter the hour when the accident occurred that necessitated medical treatment. Use the same coding used in FL 18 (Admission Hour).
49 Hematocrit Reading - EPO Related
58 Arterial Blood Gas (PO2/PA2)
68 EPO-Drug
80 Covered Days
81 Non-Covered Days
Enter the deductible amount applied by indicated payer:
Deductible Payer A
B1 Deductible Payer B
C1 Deductible Payer C
Enter the amount applied to member's co-insurance by indicated payer:
A2 Coinsurance Payer A
B2 Coinsurance Payer B
C2 Coinsurance Payer C
Enter the amount paid by indicated payer:
A3 Estimated Responsibility Payer A
B3 Estimated Responsibility Payer B
C3 Estimated Responsibility Payer C
For Rancho Coma Score bill with appropriate diagnosis for head injury.

Medicare & TPL - See A1-A3, B1-B3, & C1-C3 above.
42. Revenue Code 4 digits Required

Enter the revenue code which identifies the specific service provided. List revenue codes in ascending order. These codes are listed in Appendix Q, under the Appendices drop-down section on the Billing Manuals web page, for valid dialysis revenue codes.

A revenue code must appear only once per date of service. * If more than one of the same service is provided on the same day, combine the units and charges on one line accordingly.

When billing outpatient hospital radiology, the radiology revenue code may be repeated, but the corresponding HCPCS code cannot be repeated for the same date of service. Refer to instructions under FL 44 (HCPCS/Rates).

Use the following revenue codes:
114 Psychiatric Step Down
124 Psychiatric Step Down
43. Revenue code Description Text Required
Enter the revenue code description or abbreviated description.
44. HCPCS/Rates/ HIPPS Rate Codes 5 digits Conditional

Enter only the HCPCS code for each detail line. Use approved modifiers listed in this section for hospital based transportation services.

Complete for laboratory, radiology, physical therapy, occupational therapy, and hospital based transportation. When billing HCPCS codes, the appropriate revenue code must also be billed.

HCPCS codes must be identified for the following revenue codes:
 
  • 030X Laboratory
  • 032X Radiology – Diagnostic
  • 033X Radiology – Therapeutic
  • 034X Nuclear Medicine
  • 035X CT Scan
  • 040X Other Imaging Services
  • 042X Physical Therapy
  • 043X Occupational Therapy
  • 054X Ambulance
  • 061X MRI and MRA


HCPCS codes cannot be repeated for the same date of service. Combine the units in FL 46 (Units) to report multiple services.

The following revenue codes always require a HCPCS code. Please reference the Bulletins web page for a list of physician-administered drugs that also require an NDC code.

When a HCPCS code is repeated more than once per day and billed on separate lines, use modifier 76 to indicate this is a repeat procedure and not a duplicate.
0252 Non-Generic Drugs
0253 Take Home Drugs
0255 Drugs Incident to Radiology
0257 Non-Prescription
0258 IV Solutions
0259 Other Pharmacy
0260 IV Therapy General Classification
0261 Infusion Pump
0262 IV Therapy/Pharmacy Services
0263 IV Therapy/Drug/Supply Delivery
0264 IV Therapy/Supplies
0269 Other IV Therapy
0631 Single Source Drug
0632 Multiple Source Drug
0633 Restrictive Prescription
0634 Erythropoietin (EPO) <10,000
0635 Erythropoietin (EPO) >10,000
0636 Drugs Requiring Detailed Coding
45. Service Date 6 digits Required For span bills only
Enter the date of service using MMDDYY format for each detail line completed.

Each date of service must fall within the date span entered in the "Statement Covers Period" field (FL 6).

Not required for single date of service claims.
46. Service Units 3 digits Required
Enter a unit value on each line completed. Use whole numbers only. Do not enter fractions or decimals and do not show a decimal point followed by a 0 to designate whole numbers (e.g., Do not enter 1.0 to signify one unit).

For span bills, the units of service reflect only those visits, miles or treatments provided on dates of service in FL 45.
47. Total Charges 9 digits Required

Enter the total charge for each line item. Calculate the total charge as the number of units multiplied by the unit charge. Do not subtract Medicare or third-party payments from line charge entries. Do not enter negative amounts. A grand total on line 23 is required for all charges.
48. Non-covered Charges Up to 9 digits Conditional

Enter incurred charges that are not payable by the Health First Colorado.

Non-covered charges must be entered in both FL 47 (Total Charges) and FL 48 (Non-Covered Charges.) Each column requires a grand total on line 23.

Non-covered charges cannot be billed for outpatient hospital laboratory or hospital based transportation services.
50. Payer Name 1 letter and text Required

Enter the payment source code followed by name of each payer organization from which the provider might expect payment.
At least one line must indicate Health First Colorado.
Source Payment Codes
B Workmen's Compensation C Medicare
D Health First Colorado E Other Federal Program F Insurance Company
G Blue Cross, including Federal Employee Program
I Other
Line A Primary Payer
Line B Secondary Payer
Line C Tertiary Payer
51. Health Plan ID 8 digits Required
Enter the provider's Health Plan ID for each payer name.
Enter the NPI number assigned to the billing provider. Payment is made to the enrolled provider or agency that is assigned this number.
52. Release of Information N/A Submitted information is not entered into the claim processing system.
53. Assignment of Benefits N/A Submitted information is not entered into the claim processing system.
54. Prior Payments Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter third party and/or Medicare payments.
55. Estimated Amount Due Up to 9 digits Conditional
Complete when there are Medicare or third-party payments.
Enter the net amount due from Health First Colorado after provider has received other third party, Medicare or member liability amount.
Medicare Crossovers
Enter the sum of the Medicare coinsurance plus Medicare deductible less third-party payments and member payments.
56. National Provider Identifier (NPI) 10 digits Required
Enter the billing provider's 10-digit National Provider Identifier(NPI).
57. Other Provider ID   Optional
Submitted information is not entered into the claim processing system.
58. Insured's Name Up to 30 characters Required
Enter the member's name on the Health First Colorado line.
Other Insurance/Medicare
Complete additional lines when there is third party coverage. Enter the policyholder's last name, first name, and middle initial.
60. Insured's Unique ID Up to 20 characters Required
Enter the insured's unique identification number assigned by the payer organization exactly as it appears on the health insurance card. Include letter prefixes or suffixes shown on the card.
61. Insurance Group Name 14 letters Conditional
Complete when there is third party coverage.

Enter the name of the group or plan providing the insurance to the insured exactly as it appears on the health insurance card.
62. Insurance Group Number 17 digits Conditional
Complete when there is third party coverage.

Enter the identification number, control number, or code assigned by the carrier or fund administrator identifying the group under which the individual is carried.
63. Treatment Authorization Code Up to 18 characters Conditional
Complete when the service requires a PAR.
Enter the authorization number in this FL if a PAR is required and has been approved for services.
64. Document Control Number none Conditional
65. Employer Name Text Conditional
Complete when there is third party coverage.
Enter the name of the employer that provides health care coverage for the individual identified in FL 58 (Insured Name).
66. Diagnosis Version Qualifier   Submitted information is not entered into the claim processing system.
Enter applicable ICD indicator to identify which version of ICD codes is being reported.
0   ICD-10-CM (DOS 10/1/15 and after)
67. Principal Diagnosis Code Up to 6 digits Required

Enter the exact diagnosis code describing the principal diagnosis that exists at the time of admission or develops subsequently and affects the length of stay. Do not add extra zeros to the diagnosis code.
67A. – 67Q. – Other Diagnosis 6 digits Conditional
Enter the exact diagnosis code corresponding to additional conditions that co-exist at the time of admission or develop subsequently and which effect the treatment received or the length of stay. Do not add extra zeros to the diagnosis code.
69. Admitting Diagnosis Code 6 digits Optional

Enter the diagnosis code as stated by the physician at the time of admission.
70. Patient Reason Diagnosis   Submitted information is not entered into the claim processing system.
71. PPS Code   Submitted information is not entered into the claim processing system.
72. External Cause of Injury code (E-Code) 6 digits Optional
Enter the diagnosis code for the external cause of an injury, poisoning, or adverse effect. This code must begin with an "E".
74. Principal Procedure Code/Date 7 characters and 6 digits Conditional

Enter the procedure code for the principal procedure performed during this billing period and the date on which procedure was performed. Enter the date using MMDDYY format. Apply the following criteria to determine the principle procedure:

The principal procedure is not performed for diagnostic or exploratory purposes. This code is related to definitive treatment; and

The principal procedure is most related to the primary diagnosis.
74A. Other Procedure Code/Date 7 characters and 6 digits Conditional

Complete when there are additional significant procedure codes.

Enter the procedure codes identifying all significant procedures other than the principle procedure and the dates on which the procedures were performed. Report those that are most important for the episode of care and specifically any therapeutic procedures closely related to the principle diagnosis. Enter the date using MMDDYY format.
76. Attending NPI – Required NPI – 10 digits Health First Colorado ID Required
NPI - Enter the 10-digit NPI number assigned to the physician having primary responsibility for the member's medical care and treatment. This number is obtained from the physician and cannot be a clinic or group number.
(If the attending physician is not enrolled in the Health First Colorado or if the member leaves the ER before being seen by a physician, the hospital may enter their individual numbers.)
Hospitals and FQHCs may enter the member's regular physician's 10- digit NPI in the Attending Physician ID form locator if the locum tenens physician is not enrolled in the Health First Colorado.
QUAL – Enter "1D" for Health First Colorado
Enter the attending physician's last and first name.
This form locator must be completed for all services.
77. Operating NPI   Not required
Submitted information is not entered into the claim processing system.
78 – 79. Other ID NPI – 10 digits Conditional

Complete when attending physician is not the PCP or to identify additional physicians.

Ordering, Prescribing, or Referring NPI - when applicable

NPI - Enter up to two 10-digit NPI numbers, when applicable. This form locator identifies physicians other than the attending physician. If the attending physician is not the PCP or if a clinic is a PCP agent, enter the PCP NPI number as the referring physician. The name of the Health First Colorado member's PCP appears on the eligibility verification. Review either for eligibility and PCP. Health First Colorado does not require that the PCP number appear more than once on each claim submitted.

The attending physician's last and first name are optional.
80. Remarks Text Enter specific additional information necessary to process the claim or fulfill reporting requirements.
81. Code – QUAL/CODE/VALUE (a-d)   Submitted information is not entered into the claim processing system.

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UB-04 Outpatient PT Claim Example

UB-04 Outpatient PT Claim Example

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.

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PT/OT Revisions Log

Revision Date Addition/Changes Made by
12/1/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive. HPE (now DXC)
1/5/2017 Updates based on Colorado iC Stage II Provider Billing Manual_Bundle 2 Comment Logv0_2.xlsx HPE (now DXC)
1/13/2017 Updates based on Colorado iC Stage II Provider Billing Manual_Bundle 2 Comment Logv0_3.xlsx HPE (now DXC)
1/13/2017 Updates based on Colorado iC Stage II Provider Billing Manual_Bundle 2 Comment Logv0_4.xlsx HPE (now DXC)
2/3/2017 Updates based on 1/30/2017 Department approval email. HPE (now DXC)
3/6/2017 Changed information about checking a member's ID in the eligibility portal. HCPF
5/26/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
8/22/2017 Organizational updates throughout. Clarified policy on IFSPs and CCBs. HCPF
11/3/2017 Incorporated policy from discontinued benefit coverage standard. Updated benefit limitation policy. HCPF
1/15/2018 Updated modifier and procedure code tables, included provider qualifications including other medical professionals, included eligible place of service code table, optimized content throughout. HCPF
2/28/2018 Removed NDC supplemental qualifier - not relevant for PT/OT providers DXC
6/15/2018 Updated timely filing information and removed references to LBOD; removed general billing information already available in the General Provider Information manual; added clarification concerning therapy assistants; reformatted and updated the covered procedure code table; added clarification concerning Early Intervention PT/OT Prior Authorizations. DXC
6/27/2018 Updated ToC, timely filing HCPF
6/28/2018 Removed duplicated references, continuation references, institutional certification form HCPF
11/1/2018 Updated documentation policy (page 4); removed PAR requirement from 97760 (page 13) HCPF
12/21/2018 Clarification to signature requirements HCPF
3/18/2019 Clarification to signature requirements HCPF
4/4/2019 Included 96112 96113. Identified 97799 for functional dry needling. HCPF
9/17/2019 Added POS 99 – Community Based Location to allowable POS codes. Added 'specific non-covered modalities' from October 2019 Provider Bulletin. Added 'reporting of service units' from October 2019 Special Provider Bulletin. HCPF
2/12/2020 Converted to web page HCPF
2/14/2020 Updated coding table for 2020 HCPS changes HCPF
4/27/2020 Updated ‘Visit/Encounter Notes’ section in Documentation Requirements to allow note formats like APSO instead of strictly SOAP, effective 5/1/20.  HCPF
6/4/2020 Added field 17.b instruction to OPR policy. Corrected PAR status of 92526 from ‘sometimes’ to ‘always’ to match interChange system function. HCPF
9/14/2020 Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table HCPF
11/3/2020
  • Added telemedicine POS 02 reference to the Coding section.
  • Added POS 13 to the Coding section (allowed retroactively to align with interChange configuration)
  • Clarified that CPT 97755 does not require mod 96 or 97 in the coding table.
  • Revised PAR requirement section to clarify that either a prescription or approved Plan of Care is necessary.
HCPF