Covered and Noncovered Services : Covered Services and Requirements

Therapy Services

As a result of 2005 Wisconsin Act 25, the 2005-2007 biennial budget, outpatient hospitals follow the program requirements provided in the Therapies service area when providing PT, OT, and SLP services. These program requirements include covered services and related limitations, PA, requirements and procedures, claim submission requirements, and reimbursement.

Note: PT and OT services provided during an outpatient hospital cardiac rehabilitation clinic visit, with cardiac rehabilitation team monitoring or physician electrocardiographic monitoring also provided, are an exception.

Physical Therapy and Occupational Therapy Services Provided During Outpatient Hospital Cardiac Rehabilitation Clinic Visits

For a PT or OT service to be considered part of an outpatient hospital cardiac rehabilitation clinic visit, all of the following must be true:

• The PT or OT service is provided as part of a multidisciplinary approach and cannot be separated from the outpatient hospital cardiac rehabilitation clinic visit.
• The visit is provided in a licensed outpatient hospital facility.

Requirements

When providing a PT or OT service as part of an outpatient hospital cardiac rehabilitation clinic visit, providers should note the following:

• PA is not required.
• The PT or OT service may not be reimbursed separately from the cardiac rehabilitation clinic visit. Claims for cardiac rehabilitation clinic visits may be submitted using the 837I transaction or the paper UB-04 Claim Form and the appropriate cardiac rehabilitation clinic revenue code. Reimbursement for the revenue code includes all medically necessary services that are provided as part of the cardiac rehabilitation clinic visit. Providers should refer to Wis. Admin. Code § DHS 101.03(96m) for the definition of medically necessary.