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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Prescription/Referral 

All PT/OT services must have a written order, referral, or prescription by any of the following:

    • Physician (M.D. or D.O.)
    • Physician's assistant
    • Nurse practitioner
    • An approved Individualized Family Service Plan (IFSP) for Early Intervention PT/OT

NPI Numbers

Ordering, prescribing, and referring (OPR) National Provider Identification (NPI) numbers be on the claim form:

    • All Outpatient PT/OT claims must contain the valid NPI number of the OPR physician, physician assistant, nurse practitioner, or provider associated with an Individualized Family Service Plan (IFSP), in accordance with Program Rule 8.125.8.A.
      • Community Centered Boards may have their NPI listed as the referring NPI for IFSP-ordered early intervention services.
    • All physicians, physician assistants, nurse practitioners, or providers associated with an IFSP who order, prescribe, or refer Outpatient PT/OT services for Medicaid members must be enrolled in Health First Colorado.  OPR Providers can begin enrollment on Health First Colorado's website.
      • The new enrollment requirement for OPR providers does not include a requirement to see Medicaid members or to be listed as a Medicaid provider for patient assignments or referrals.
      • Physicians or other eligible professionals who are already enrolled in Health First Colorado as participating providers and who submit claims to Health First Colorado are not required to enroll separately as OPR providers.
    • Field 17.b on the CMS1500 claim form must be used for the OPR NPI number.

Early Intervention

Outpatient PT/OT ordered in conjunction with an approved IFSP for Early Intervention may not necessarily have an ordering provider. Under this circumstance alone the rendering provider must use their own NPI number as the OPR NPI number.

  • Early Intervention Outpatient PT/OT claims must have modifier 'TL' attached on the procedure line item for Health First Colorado to identify that the services rendered were associated with an approved IFSP.
    • Any claim with modifier 'TL' attached must be for a service ordered by an approved IFSP and delivered within the time span noted in the IFSP.
    • If the OPR NPI on the claim is that of the rendering provider, and the claim does not have modifier 'TL' attached, the claim is subject to recovery.

Reference

Colorado Department of Health Care Policy & Financing

Physical and Occupational Therapy Billing Manual

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