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Medical Policy Update: Physical Therapy in the Home and Outpatient Setting

Effective December 10, 2019, Horizon BCBSNJ will change the way we consider certain professional claims based on our inclusion of Horizon BCBSNJ Medicare Advantage (MA) claims in the scope of our medical policy, Physical Therapy in the Home and Outpatient Setting.

Access our Medical Policy Manual to review this medical policy content.¹

Claims submitted for services provided on and after December 10, 2019 to patients enrolled in Horizon BCBSNJ Medicare Advantage (MA) plans will be processed as follows.

  • Regardless of the submitted diagnosis code(s), the services represented by CPT® codes 97169, 97170, 97171 and 97172 will be denied as not medically necessary..

  • Regardless of the submitted diagnosis code(s), information will be requested to help us determine the medical appropriateness of the services represented by CPT codes 97032 or 97763. Following our review of medical record information, these services may be denied as not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, based on a national coverage determination or local coverage determination.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been canceled or postponed, the changes will be applied to claims for dates of service on and after December 10, 2019.

CPT® is a registered mark of the American Medical Association.

¹The content of Horizon BCBSNJ medical policies that apply to Horizon BCBSNJ MA plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

Published on: September 9, 2019, 02:36 a.m. ET
Last updated on: June 23, 2021, 08:47 a.m. ET