Outpatient Therapy Daily Maximum

Reimbursement Policy:
Outpatient Therapy Daily Maximum

Effective Date:
October 2, 2005

Last Revised Date:
April 26, 2017

Purpose:
Provide clarification on outpatient therapy services that Horizon BCBSNJ determined in October 2005 shall be reimbursed at a maximum allowed amount per member per day. This policy applies to professional providers.

Scope:
All products are included, except:

  • Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap)
  • COB

All Insured and Administrative Services Only (ASO) accounts are included.

Policy:
Horizon BCBSNJ has identified outpatient therapy services that shall be reimbursed at a limited maximum allowed amount per member per day. The procedure codes include:

CPT codes
97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172, 97530, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97762, 97799

HCPCS codes
G0129, G0151, G0176, G0177, G0237, G0238, G0239, G0281, G0282, G0283, G0329, G9042, G9043, G9044, S8940, S8948, S8950, S8990, S9056, S9090, S9129, S9131, S9476

The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:
When billed separately or in conjunction with the services listed above, these therapy services shall be reimbursed at a combined maximum allowed amount per member per day.

In instances where the provider is participating, there shall be no subscriber liability.

In instances where the provider is not participating, subscriber liability shall be up to billed charges.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

History:
4/26/2017: Termination of procedure codes 97532 and 97533 effective 5/31/2017

Policy 103_v1.0_04262017