Description
For HCPCS/CPT Codes with a PC/TC Indicator “7” in the Medicare Physician Fee Schedule Data Base, payment may not be made if the service is provided to a hospital inpatient by a physical therapist, occupational therapist, or speech language therapist in private practice.
Affected Code(s)
HCPCS/CPT Codes with a PC/TC Indicator of "7" in the MPFSDB
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 Claims Processing Manual: CMS Publication 100-04; Chapter 23, - Fee Schedule Administration and Coding Requirements; Addendum- MPFSDB File Record Layout and Field Descriptions (For Historical Medicare Physician Fee Schedule Database (MPFSDB) Layouts 2001 – 2018, refer to https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Downloads/Historical-MPFSDB-Layouts.pdf located on the CMS Physician Fee Schedule web page: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched)
8. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
9. AMA CPT Codebook
10. HCPCS Level II Codebook