The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. As of January 1, 2018, there are two informational modifiers which should be used when reporting these two different types of services. Since physical therapy services may be either habilitative or rehabilitative, the appropriate modifier needs to be used when reporting these services.
What's the Difference?
Habilitative (modifier 96): services that help a person DEVELOP skills or functions they didn't have before.
Rehabilitative (modifier 97) services that help a person RESTORE functions which have become either impaired or lost.
Requirements may vary from payer to payer. Let's examine some key concepts excerpted from one payer's policy (emphasis added):
The therapy is aimed at improving, adapting or restoring functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality; and
There is an expectation that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time
The therapy is intended to maintain or develop skills needed to perform ADLs or IADLs which, as a result of illness (including developmental delay), injury, loss of a body part, or congenital abnormality, either:
have not (but normally would have) developed; or
are at risk of being lost; and
There is the expectation that the therapy will assist development of normal function or maintain a normal level of function;
An individual would either not be expected to develop the function or would be expected to permanently lose the function (not merely experience fluctuation in the function) without the habilitative service.
- Amerigroup Guideline #CG-REHAB-04
The above policy includes more descriptive requirements than the simplified description at the beginning of this article. As you can see, it is necessary to verify payer policies to ensure coverage requirements for medical necessity are met. Don't forget to also make sure that your documentation clearly identifies the type of service as well as payer requirements to ensure compliance in the case of an audit.
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
In January, the U.S. Department of Health and Human Services (HHS) issued updates to the privacy regulations regarding the confidentiality of patient information of substance use disorder patients (42 CFR Part 2). This notice included references to better alignment with HIPAA regulations, but did state that Part 2 is more protective ...
For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...
Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?
Why would a chiropractor be concerned about depression screenings when you aren’t trained to be a mental health provider? The answer lies in patient outcomes. Many quality care organizations recommend depression screenings for patients with a chronic condition. According to The National Institute of Mental Health, “People with other chronic ...
The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. ...
Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time.
It should be noted that while ...
Date: October 9-10 Time: 9-3 MST
QPro Con is featuring a virtual event with keynote speakers and experts with years of hands-on experience in the healthcare industry. Stay ahead of the changes and keep informed of important information that affects the healthcare community.
Attendees receive 12 FREE CEUs with the purchase ...