Description

Always Therapy Services are eligible therapy procedures (i.e., therapy modalities Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST)) performed by a certified therapist. Such procedure codes are assigned a therapy indicator of "5" by CMS.

Practice Expense (PE) is the portion of the resources used in a facility setting that addresses the cost of the facility, including the building, supplies and non-provider staff costs. 

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) allows facility reimbursement for multiple therapy services performed on the same day at the same hospital system with the same federal tax ID, according to the criteria outlined in this policy.

Reimbursement Guidelines

Multiple Always Therapy services will be subject to a 50% reduction on the PE Relative Value Unit (RVU). Facility reimbursement will be based on the following:

• Primary procedure, indicated by the highest PE Relative Value Unit (RVU) – 100% of the PE RVU 
• Secondary procedure(s) – 50% of the PE RVU 

The multiple therapy service reduction applies across all therapy modalities.

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com. 

Related policy

Bundling Guidelines

References

Centers for Medicare and Medicaid Services (CMS) Transmittal #1194 https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1194OTN.pdf 

Centers for Medicare and Medicaid Services, Physician Fee Schedule (PFS) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-File

History

5/1/2024 New policy developed. Notification on 5/01/2024 for effective date 7/10/2024 (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Blue Cross and/or Blue Shield Plan Members who seek care from the NC service area). This policy does not apply to Blue Cross NC Members who seek care in other states.

This policy relates only to the services and/or supplies described herein. Please refer to the applicable Member’s Benefit Booklet for availability of benefits. Member’s benefits may vary according to benefit design; therefore, Member benefit language should be reviewed before applying the terms of this policy. 

Legal

Reimbursement policy is not an authorization, certification, explanation of benefits or a contract. Benefits and eligibility are determined before medical guidelines and payment guidelines are applied. Benefits are determined by the Member’s group contract and subscriber certificate that is in effect at the time services and/or supplies are rendered. This document is solely provided for informational purposes only and is based on research of current medical literature and review of common medical practices in the treatment and diagnosis of disease. Medical practices and knowledge are constantly changing and Blue Cross NC reserves the right to review and revise its medical and reimbursement policies periodically.

BLUE CROSS^®, BLUE SHIELD^® and the Cross and Shield symbols are marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and trade names are the property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.