• Indicate “11X” or “12X” type of bill
• First digit – type of facility ( 1-Hospital)
• Second digit – bill classification (1-Inpatient Hospital, including Medicare Part A or 2-Inpatient Hospital for Medicare Part B)
• Third digit – frequency (e.g., admit through discharge claim)
• Refer to contractual reimbursement terms to determine if billing is based on rehabilitation room and board revenue codes or HIPPS Case Mix Group codes. Typically only Medicare Advantage contracts are negotiated based on the inpatient prospective payment system. (Note: HIPPS Case Mix Group code must be billed with revenue code 024).
• Room and board revenue code should be one of the following: 118, 128, 138, 148 or 158
• Submit actual number of days the member was in the facility. Day of discharge or death is not considered a covered day, unless admitted and discharged/deceased on the same day.
• Individual therapist providing occupational, physical and/or speech therapy may not bill separately for services provided in the facility.
Note: All charges for physician services should be billed separately on the CMS-1500 claim form.
To be eligible for admission to a Medicare-certified rehabilitation hospital or unit, members must require intensive rehabilitation services. The general threshold for establishing the need for inpatient hospital rehabilitation services is that the member must require and receive at least 3 hours of occupational and/or physical therapy per day. The therapy must be provided as treatment for one or more of the following conditions: amputation, brain injury, burns, congenital deformity, joint replacement, neurological disorders (including multiple sclerosis, motor neuron diseases, muscular dystrophy, polyneuropathy and Parkinson's disease), steoarthritis/hip, Polyarthritis (including rheumatoid arthritis), spinal cord injury, stroke, systemic vasculitis, and trauma (major or multiple).
Rehabilitation facilities are contracted to provide occupational, physical, and speech therapy.
• OT – Occupational therapists evaluate and treat problems interfering with functional performance. Targeted areas may include motor control/coordination, sensory motor skills, cognition, and visual perceptual skills.
• PT – Physical therapists evaluate and treat components of movement, which include range of motion, muscle strength, muscle tone, endurance, posture, balance and coordination, and mobility.
• RT – Respiratory therapists assess, evaluate, treat, manage and care for patients with respiratory problems (e.g., asthma or emphysema). Clinical tasks are diagnostic and therapeutic to include administration of medical gases (i.e., oxygen, helium, and carbon dioxide), aerosol and humidity therapy, intermittent positive-pressure breathing therapy, incentive spirometry, artificial mechanical ventilation, arterial blood gas analysis, and pulmonary function testing. Respiratory therapists work under the supervision of physicians to administer prescribed respiratory therapy to patients with chronic illnesses. Outpatient services are only covered when provided in the comprehensive outpatient rehabilitation facility.
• ST – Speech-language pathologists evaluate and treat conditions relating to speech including: motor speech and voice disorders; expressive and receptive language disorders; articulation fluency; attention, memory, problem solving, and other cognitive deficits.
Note: Inpatient Rehabilitation Facilities are also contracted to provide medical and nursing services.