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License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA websiteExternal Website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

These materials contain Current Dental Terminology, Fourth Edition (CDT), copyright © 2002, 2004 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.

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  1. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
  2. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association websiteExternal Website.
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Home Health Outpatient Therapy Billing

Outpatient therapy services may be furnished by a home health agency (HHA) to individuals who are not homebound or otherwise are not receiving services under a home health plan of care (POC). These services are not paid under the Home Health Prospective Payment System (HH PPS). Instead, the home health agency's reimbursement for outpatient therapy services is calculated using the Medicare Physician's Fee Schedule (MPFS)External Website.

HHA outpatient therapy claims can be entered into the Fiscal Intermediary Standard System (FISS) Home Health Claims Entry option 26 (accessible from FISS Main Menu option 02). See Chapter 4 – Claims and Attachments MenuPDFof the Fiscal Intermediary Standard System (FISS) Guide for information on entering Medicare claims using FISS. In addition to the usual information that is required on Medicare claims, the following identifies specific information required for HHA outpatient therapy claims.

NOTE: Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.  Refer to Medicare Learning Network (MLN) Matters® article, MM11120External PDF, Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018 for additional information.

Field Name Description

TOB

34X – HHA visits provided on an outpatient basis. ('X' denotes the frequency of bill. Frequency indicators are accessible from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications ManualExternal Website)

OCC CDS/DATES

11 Onset of symptoms/illness and the date of symptom onset.

  • When appropriate, enter one of the following occurrence codes and corresponding date:

17 Date outpatient occupational therapy (OT) plan established or last reviewed.
29 Date outpatient physical therapy (PT) plan established or last reviewed
30 Date outpatient speech-language pathology (SLP) plan established or last reviewed
35 Date treatment started for PT
44 Date treatment started for OT
45 Date treatment started for SLP

REV

Enter the appropriate revenue code:
042X – Physical therapy
043X – Occupational therapy
044X – Speech-language pathology
Please note that "X" is a placeholder which indicates the value can vary from 0-9. A complete list of revenue codes is available from the National Uniform Billing Committee (NUBC) Official UB-04 Data Specifications ManualExternal Website

HCPC

Enter the appropriate HCPCS codes that relates to the therapy service provided. Refer to the "Annual Therapy UpdateExternal Website" Web page on the CMS website and the Medicare Claims Processing Manual, Pub. 100-04, Ch. 5, §10.6External PDFfor more information .

MODIFS

Following the HCPCS code, enter one of the following therapy modifiers. 

Therapy Modifiers
GN
– Services personally provided by a speech-language therapist.
GO – Services personally provided by an occupational therapist
GP – Services personally provided by a physical therapist
KX – Outpatient therapy services when the beneficiary is qualified for exception to the therapy caps.

Severity Modifiers (effective for dates of service on or after January 1, 2013, and before January 1, 2019)
CH – 0 percent impaired, limited or restricted
CI – At least 1 percent but less than 20 percent impaired, limited or restricted
CJ – At least 20 percent but less than 40 percent impaired, limited or restricted
CK – At least 40 percent but less than 60 percent impaired, limited or restricted
CL – At least 60 percent but less than 80 percent impaired, limited or restricted
CM – At least 80 percent but less than 100 percent impaired, limited or restricted
CN – 100 percent impaired, limited or restricted

TOT UNIT

Report the units as the number of times the procedure was performed.

Effective for dates of service on or after January 1, 2013, and before January 1, 2019, for the G code line, enter 1 unit.

Effective for dates of service on or after January 1, 2019, HCPCS G-codes for functional reporting are no longer required on claims for therapy services.

COV Unit

Key the number of covered units for the services billed. Ensure the appropriate increment is reflected for the therapy being billed.

Effective for dates of service on or after January 1, 2013, and before January 1, 2019. for the G code line, enter 1 unit.

Effective for dates of service on or after January 1, 2019, HCPCS G-codes for functional reporting are no longer required on claims for therapy services.

TOT CHARGE

Key the total charge per revenue code. The decimal point is optional (i.e., $1500.00 can be keyed as 1500.00 or 150000). However, you must key two zeroes (00) for the cents amount.

Effective for dates of service on or after January 1, 2013, and before January 1, 2019, for the G code line, enter a nominal charge (example - $0.01)

Effective for dates of service on or after January 1, 2019, HCPCS G-codes for functional reporting are no longer required on claims for therapy services.

SERV DATE

Enter the line item date for the service provided.

ATT PHYS NPI
Required

Enter the national provider identifier (NPI) of the physician certifying the therapy plan of care.

L
Required

Enter the last name of the physician certifying the therapy plan of care.

F
Required

Enter the first name of the physician certifying the therapy plan of care.

M
Optional

Enter the middle initial of the physician certifying the therapy plan of care.

REF PHYS NPI
Conditionally Required

Enter the NPI of the physician certifying the therapy plan of care only in cases where different professionals certify the occupational therapy (OT), physical therapy (PT), or speech-language pathology (SLP) plan of care.

L
Conditionally Required

Enter the last name of the physician certifying the therapy plan of care only in cases where different professionals certify the OT, PT, or SLP plan of care.

F
Conditionally Required

Enter the first name of the physician certifying the therapy plan of care only in cases where different professionals certify the OT, PT, or SLP plan of care.

M
Optional

Enter the middle initial of the physician certifying the therapy plan of care only in cases where different professionals certify the OT, PT, or SLP plan of care.

Additional Resources

Refer to the following CMS Internet Only ManualsExternal Website(IOMs) for coverage and billing regulations for home health outpatient therapy services:

Updated: 12.23.19

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