Description
When reporting service units for untimed codes (excluding Modifiers -KX, and -59) where the procedure is not defined by a specific timeframe, the provider may not exceed (1) in the units billed column per date of service.
Affected Code(s)
92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92609, 97012, 97016, 97018, 97022, 97024, 97028, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, G0281, G0283, G0329
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Medicare Benefit Policy Manual: Chapter 15- Covered Medical and Other Health Services, §220- Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance; §230- Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
9. Medicare Claims Processing Manual, Chapter 5- Part B Outpatient Rehabilitation and CORF Services, §10.3.2- Exceptions Process; §10.6- Functional Reporting; §20.2- Reporting of Service Units with HCPCS
10. AMA CPT Codebook
11. HCPCS Level II Codebook