Clinical UM Guideline
Subject: Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology
Guideline #: CG-REHAB-12 Publish Date: 10/06/2021
Status: Reviewed Last Review Date: 08/12/2021
Description

This document addresses physical therapy, occupational therapy, and speech-language pathology services, also called speech therapy services provided in the home setting.

Rehabilitative services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals.

Habilitative services are intended to maintain, develop or improve skills needed to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs) (see definitions) which have not (but normally would have) developed or which are at risk of being lost as a result of illness, injury, loss of a body part, or congenital abnormality. An example is therapy for a child who is not walking at the expected age.

Note: The availability of rehabilitative and/or habilitative benefits for these services, state and federal mandates, and regulatory requirements should be verified prior to application of criteria listed below. Benefit plans may include a maximum allowable physical, occupational, or speech therapy benefit, either in duration of treatment or in number of visits. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria described below are met.

Note: For criteria of physical therapy, occupational therapy, or speech-language pathology services in the home setting, refer to applicable guidelines used by the plan. Benefits, state mandates and regulatory requirements should be verified prior to application of criteria listed below. The criteria for these services may vary by plan due to state or Centers for Medicare and Medicaid services (CMS) requirements.

Note: Please see the following related document for additional information related to home health care services:

Clinical Indications

Medically Necessary:

Physical therapy, occupational therapy, or speech-language pathology services in the home setting are considered medically necessary when both of the criteria below are met:

  1. The individual’s therapy request meets medical necessity criteria under the physical, occupational, or speech-language pathology guidelines used by the plan; and
  2. The request meets medical necessity criteria for home health care outlined in CG-MED-23 Home Health.

Not Medically Necessary:

Physical therapy, occupational therapy, or speech-language pathology services in the home setting are considered not medically necessary when the above criteria are not met.

Coding

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met:

HCPCS

 

G0151

Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes

G0152

Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes

G0153

Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes

G0157

Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes

G0158

Services performed by a qualified occupational therapist assistant in the home health or hospice setting, each 15 minutes

G0159

Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes

G0160

Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes

G0161

Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, each 15 minutes

G2168

Services performed by a physical therapist assistant in the home health setting in the delivery of a safe and effective physical therapy maintenance program, each 15 minutes

G2169

Services performed by an occupational therapist assistant in the home health setting in the delivery of a safe and effective occupational therapy maintenance program, each 15 minutes

S9128

Speech therapy, in the home, per diem

S9129

Occupational therapy, in the home, per diem

S9131

Physical therapy, in the home, per diem

 

 

ICD-10 Diagnosis

 

 

All diagnoses

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met.

History

Status

Date

Action

Reviewed

08/12/2021

Medical Policy & Technology Assessment Committee (MPTAC) review.

New

08/13/2020

MPTAC review. Initial document development. Moved content from CG-REHAB-04 Rehabilitative and Habilitative Services: Physical Medicine/Physical Therapy; CG-REHAB-05 Rehabilitative and Habilitative Services: Occupational Therapy; and CG-REHAB-06 Rehabilitative and Habilitative Services: Speech-Language Pathology guideline to new clinical utilization management guideline with updated title to address therapy services in the home setting.

 

 


Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan’s or line of business’s members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

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