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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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Conditions for Coverage

Outpatient therapy services furnished to a beneficiary by a physical, occupational or speech therapist are payable only when furnished in accordance with certain conditions.

The following conditions apply:

    • Services are or were required because the individual needed therapy services (see Medical Necessity);
    • A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP (see Plan of Care);
    • Services are or were furnished while the individual is or was under the care of a physician (see Under the Care of Physician/NPP);
    • In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above three conditions are met. Certification is required for coverage and payment of a therapy claim (See Certification and Re-certification); and
    • Claims submitted for outpatient (and CORF) PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care.


Medicare Benefit Policy Manual Chapter 15 § 220.1

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