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2012 Texas Medicaid Provider Procedures Manual

Children’s Services Handbook : 2. Medicaid Children’s Services Comprehensive Care Program (CCP) : 2.3 Comprehensive Outpatient Rehabilitation Facilities (CORFs)and Outpatient Rehabilitation Facilities (ORFs) : 2.3.3 Occupational Therapy

A procedural modifier is required when submitting claims for OT services. Providers must use modifier GO for OT services. Procedural modifiers are not required for evaluations and reevaluations.
Evaluations (procedure code 97003) are limited to once every 180 calendar days, any provider. Reevaluations (procedure code 97004) are limited once per 30 calendar days, any provider.
An evaluation or reevaluation performed on the same day as therapy from a different therapy type must be performed at distinctly separate times to be considered for reimbursement.
If a therapy evaluation or reevaluation procedure code and like therapy procedure codes are billed for the same date of service by any provider, the like therapy evaluation or reevaluation will be denied.
Occupational therapy evaluation (procedure code 97003) or reevaluation (procedure code 97004) will be denied as part of the following occupational therapy procedure codes billed with Modifier GO.
The following procedure codes are billed in 15-minute increments:
Procedure codes that may be billed in multiple quantities (i.e., 15 minutes each) are limited to two hours (eight units) per day of individual, group, or a combination of individual and group therapy, per therapy type (two hrs. of OT and two hrs. of PT). Each 15 minutes equals one unit.
All 15-minute increment procedure codes are based on the actual amount of billable time associated with the service. For those services for which the unit of service is 15 minutes (1 unit = 15 minutes), partial units must be rounded up or down to the nearest quarter hour.
The documentation retained in the client’s file must include the billable start time, billable stop time, total billable minutes, and activity that was performed.
To calculate billing units, count the total number of billable minutes for the calendar day for the client, and divide by 15 to convert to billable units of service. If the total billable minutes are not evenly divisible by 15, minutes greater than 7 are converted to 1 unit and 7 or fewer minutes are converted to 0 unit.
For example, 68 total billable minutes/15 = 4 units + 8 minutes. Since the 8 minutes are more than 7 minutes, those 8 minutes are converted to 1 unit. Consequently, 68 total billable minutes = 5 units of service. The following table indicates the time intervals for 0 through 8 units:
Procedure code 97150 will be denied if billed on the same date of service by the same provider as procedure code 97750.
Electrical stimulation therapy (procedure code 97032) may be considered with documentation of medical necessity.

Texas Medicaid & Healthcare Partnership
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