CPT code and Description
G8991 – Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
G8992 – Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting
G8993 – Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals
G8994 – Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
Occupational therapy services
Occupational therapy services include:
• Assessing, improving, developing, or restoring functions impaired or lost through illness, injury, or deprivation.
• Improving ability to perform tasks for independent functioning when functions are lost or impaired.
• Preventing initial or further impairment or loss of function through early intervention
Occupational Therapy: A branch of rehabilitative health that uses assessments and interventions to develop, recover, or maintain the meaningful activities, or occupations, of individuals. These services may include comprehensive evaluations of the client’s home and other environments (e.g., workplace, school), recommendations for adaptive equipment and training in its use, and guidance and education for family members and caregivers.
Occupational Therapy: The CPT physical medicine and rehabilitation codes, as well as other services such as splints, strapping, testing, and assessments (97010-97028, 97032-97036, 97039, 97110-97124, 97129, 97130, 97139, 97140, 97150, 97530-97546, 97597-97610, 97750- 97755, 97760-97763, 97799, 29105-29131, 29505, 29515, 29240-29280, 92526, 92610-92617, 95851-95852, 95999, 96105, and 96110) may be submitted by an occupational therapist.
Evaluations and re-evaluation services performed by an occupational therapist should be submitted using CPT codes 97165-97168. These codes may be reported separately if the patient’s condition requires significant separately identifiable services, above and beyond the usual pre-service and post-service work associated with the procedure performed.
To begin reporting of a second functional limitation.
At the time reporting is begun for a new and different functional limitation, within the same episode of care (i.e., after the reporting of the prior functional limitation is ended). Reporting on the second functional limitation, however, is not begun until the DOS of the next treatment day — which is day one of the new progress reporting period. When the next functional limitation to be reported is NOT defined by one of the other three PT/OT categorical codes, the G-code set (G8990 – G8992) for the “other PT/OT primary” functional limitation is used, rather than the G-code set for the “other PT/OT subsequent” ̶ because it is the first reported “other PT/OT” functional limitation. This reporting begins on the DOS of the first treatment day following the mobility “discharge” reporting, which is counted as the initial service for the “other PT/OT primary” functional limitation and the first treatment day of the new progress reporting period. In this case, G8990 and G8991, along with the corresponding modifiers, are reported on the claim for therapy services
OUTPATIENT PHYSICAL, RESPIRATORY, SPEECH, AND OCCUPATIONAL THERAPY SERVICES
A. Summary
Blue Shield reimburses facilities for outpatient Physical, Respiratory, Speech, and Occupational Therapy
Services using one of the following payment methodologies:
• Per Visit Rate
• Percentage of Charges
Please refer to your agreement to determine which payment methodology applies to your facility and to view a complete listing of required Revenue and CPT/HCPCS Codes.
Compensation for the facility’s provision of outpatient Physical Therapy, Respiratory Therapy, Speech Therapy, and Occupational Therapy Services provided to HMO or Medicare Advantage members is generally the financial responsibility of the member’s IPA or medical group
Example of Reimbursement Calculation
For Facilities Under a Per Visit Rate Agreement
For Physical, Respiratory, Speech, and Occupational Therapy covered services provided by the facility to a member, Blue Shield will pay the facility the per visit rate.
Medicare MPPR Rules
Medicare applies an MPPR to the PE payment when more than one unit or procedure is provided to the same patient on the same day, i.e., the MPPR applies to multiple units as well as multiple procedures. Many therapy services are time-based codes, i.e., multiple units may be billed for a single procedure. The MPPR applies to all therapy services furnished to a patient on the same day, regardless of whether the services are provided in one therapy discipline or multiple disciplines, for example, physical therapy, occupational therapy, or speech-language pathology.
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