Resources

The Preferred Physical Therapy Network consists of therapists who have agreed to provide our members with quality services in an efficient and effective manner. A new physical therapist (PT) who joins the Preferred Physical Therapy Network will be on a provisional status for two years in order to determine eligibility for continued participation. The provider's National Provider Identifier (NPI) should be used when filing claims. Benefits for services for physical therapy are determined based on the member's contract benefits. For general information, refer to the Provider Manual.

Covered Services

For physical therapy to be medically necessary, it must be reasonable and necessary for the patient's diagnosis or treatment of the patient's condition. Medical necessity is indicated when:

• The diagnosis established by the physician or advanced practice provider supports utilization of the therapy. Initial evaluation is covered without physician referral; however, the physician must sign the orders or the plan of care.
   
• There is documentation of objective physical and functional limitations (strength/range of motion [ROM]/mobility/activities of daily living [ADL] levels).
   
• Therapy is provided until functional level for normal ADLs (may include modified return-to-work level) or plateau is reached but not necessarily back to pre-morbid functional status.
   
• There is a plan of care that includes treatment services that are expected to result in improvement of these limitations in a reasonable and generally predictable period of time. The amount, frequency and duration of the services must be reasonable.
   
• The services must be one-to-one.
   
• The services are skilled. These services must be of a level of complexity and sophistication, or the condition of the member must be such that the services required can be safely done and effectively performed only by a qualified PT or under his/her supervision when allowed by the patient’s contract.

Services such as the application of hot and cold packs, use of exercise equipment, and repetitive exercises do not ordinarily require the skills and full attention of a qualified physical therapist; therefore, they are not separately billable. If such treatments are given as a prerequisite to a skilled physical therapy procedure, they are considered part of that modality and are not separately billable.

Noncovered Services

Preferred PTs are responsible for notifying the patient of services that are not medically necessary for treatment of his/her condition. The Notification of Noncovered Services Form is an example of a noncovered statement that can be used. The patient should sign the statement before the services are rendered. Be sure to keep the signed copy in the patient's medical record. Please refer to the Provider Manual on our website for details and examples.

Examples of Noncovered Services:

• Treatments that do not have a physician referral (the initial evaluation visit does not require physician referral)
   
• Services considered a routine part of nursing care (e.g., turning patients to prevent pressure areas, walking patients to maintain mobility, routine dressing changes)
   
• Services that do not require the professional skills of a qualified physical therapist (e.g., hot packs/cold packs, except for instances of documented paresthesia, wounds)
   
• Repetitive services/treatments not requiring the skills of a physical therapist (e.g., general supervision of exercises previously taught to the member or caregiver, exercise equipment, Stairmaster, treadmill, bicycle)
   
• Group therapy
   
• Services related to activities for the general good and well-being of patients such as general exercise to promote overall fitness and flexibility, and activities to provide diversion or general motivation
   
• Endurance enhancing activities
   
• Services provided when the patient's expected restoration potential is insignificant in relation to the extent and duration to the physical therapy services required to achieve such potential
   
• Passive exercises not related to restoring specific loss of function
   
• Maintenance care (e.g., lack of progress in restoring function/plateau)

Remember: Blue Cross and Blue Shield of Alabama does not provide benefits for professional services of a physical therapist rendered to a member who is related to the physical therapist by blood or marriage or who lives in the provider’s household.

Covered Providers

• Licensed PTs
• PT students are covered providers when working under the direct on-site supervision of a Preferred PT. All treatment notes must be co-signed by the supervising Preferred PT. Services should be billed using the supervising physical therapist’s NPI.
• PTs with temporary licenses are covered providers when working under the direct on-site supervision of a Preferred PT. All treatment notes must be co-signed by the supervising Preferred PT. Services should be billed using the supervising physical therapist’s NPI.
• Licensed certified physical therapist assistants (PTAs) are covered providers when working under the direction of a Preferred PT with the following provisions. Services should be billed using the supervising Preferred PT's NPI. The PT must:
  • Interpret the physician’s referral.
  • Perform the initial evaluation. 
  • Develop the treatment plan and program, including long- and short-term goals. 
  • Identify and document precautions, special problems, contraindications, goals, anticipated progress and plans for re-evaluation. 
  • Re-evaluate the patient and adjust the treatment plan as needed. 
  • Perform the final evaluation and discharge planning. 
  • Implement (perform the first treatment) and supervise the treatment program. The PT must co-sign each treatment note written by the PTA. 
  • Indicate he/she has directed the care of the patient and agrees with the documentation as written by the PTA for each treatment note. 
  • Render the hands-on treatment, write and sign the treatment note every 10th visit.
• Certified PTA students are covered providers when working under the direct on-site supervision of a Preferred PT or under the direct on-site supervision of a licensed PTA working under a Preferred PT. All treatment notes must be co-signed by the supervising Preferred PT. Services should be billed under the supervising PT’s NPI.
• PTAs with temporary licenses are covered providers when working under the direct on-site supervision of a Preferred PT or under the direct on-site supervision of a licensed PTA with the approval of the supervising PT. All treatment notes must be co-signed by the supervising Preferred PT. Services should be filed using the supervising PT’s NPI.

Noncovered Providers of Physical Therapy Services 

Athletic trainers, exercise physiologists, massage therapists, registered nurses, licensed practical nurses, certified strength trainers, secretaries and office personnel are not considered covered providers. Services performed by these providers are noncovered. Covered providers can vary depending on the patient’s contract plans. To determine eligible providers, refer to Eligibility & Benefits.

Filing for these kinds of services, as well as occupational and speech therapy services, under the Preferred PT’s NPI is not acceptable and is not reimbursable.

Services Performed in a School Setting

There has been an increased volume of therapy services performed in school settings. Schools are not a permissible place of service unless the member’s benefits explicitly state otherwise or there is government funding available for these services. 

Note: It is not appropriate to bill a patient’s insurance for government-funded services. 

Blue Cross contracted providers agree not to discriminate when providing healthcare services. Therefore, providers are not allowed to bill a patient with insurance differently than a patient 
without insurance. 

Per the Preferred Physical Therapy Contract, article II, number 1, and article III, number 14c: 
“Providers agree to provide each member the medical services for which benefits are provided by a member’s specific Blue Cross and Blue Shield of Alabama benefit agreement under which the member is covered only when and to the extent that such services are medically necessary. Such services shall be provided to each member in a non-discriminatory manner. Such services, including billing for services, will be provided to each member in the same manner and in accordance with the same standards as the provider’s other, non-Blue Cross patients.  The provider agrees to make no charge for medical services which the member is not legally obligated to pay or for which no charge would be made if the member had no health insurance coverage.”

Fee schedule amounts are determined using the site-of-service differential including cost of overhead. Therefore, reimbursement would not be accurate for services performed in a setting where there is no overhead cost. Providers must meet the practice site standards outlined in the Provider Manual.  
 

Precertification

Precertification requirements are determined first by the member’s benefits. Second, if there are no benefit requirements for precertification or benefit limits, Preferred PT Network requirements apply.

Preferred PTs must submit precertification for physical therapy services rendered to a new patient beginning with the 16th visit. This process should be initiated prior to the 14th visit. If precertification is not obtained, all services associated with the 16th visit and subsequent visits will be noncovered and the patient will be held harmless. Patients may be billed if they have signed a noncovered services statement for each visit. The statement must indicate that the patient has been properly informed that the services to be rendered are not covered by Blue Cross and Blue Shield of Alabama and that the patient will be responsible for paying for the services. There are no retroactive certifications for these member contracts. When requesting precertification, complete the Physical Therapy Precertification Form and submit it to:

Attention: Physical Therapy Precertification
Blue Cross and Blue Shield of Alabama
Fax Number: 205-220-0941 

If all requested information is not received, a determination will not be made. Urgent requests for initiation of therapy (which if not answered timely could jeopardize the health of the member) are due in 72 hours and non-urgent outpatient therapy review determinations are due within seven days. Notification of the determination will be made by letter or fax. 

Note: Blue Advantage^® has a separate precertification form for therapy.

Exceptions

Precertification is not required for:

• Contracts that are secondary to Medicare or any other insurance carrier.
• ITS Host and Federal Employee Plan (FEP) contracts.
• Any contract with visit limits unless specifically noted to require precertification.

CPT Codes

Listed below are a few of the Current Procedural Terminology (CPT) codes covered under the Preferred Physical Therapy Network. Special care should be given in reporting and documenting these services.

Blue Cross covers the initial two services of isokinetic testing for a comparison of the involved and uninvolved extremity. Follow-up testing may be billed monthly, if medically necessary. Only one service may be billed at the follow-up testing. Billing a service of each motion of a joint is not reimbursable. Billing for this code should include torque curves and other graphic reports with interpretation.

Patient Discharge

Patients should be discharged when: 

• The patient is restored to normal ADL functioning level (may include modified work level).
• Reasonable goals have been achieved. 
• There is no expectation of short-term significant progress. 
• The patient is unable to participate in the treatment program for medical, psychological or 
• social reasons. 
• The patient is noncompliant with treatment plans.

Medical Record Documentation

The medical record should include: 

• Completed precertification form, if applicable.
• Signed physician referral every four to six weeks.
• Signature and credentials of the person performing the initial evaluation, which includes:
  • History 
  • Diagnosis 
  • Prior level of functioning 
  • Objective documentation including strength, ROM, levels or functioning and ADL problems
  • Goals related to problems 
  • Treatment plan including frequency and time frame
• Summary of objective/measurable data evaluating the progress toward goals (should be documented at least every four to six weeks).
• Progress notes referring back to goals and progress toward goals.
• Discharge summary – including date of last visit, status, outcome of goals and home programming.
• Daily treatment notes documenting modalities and procedures, written and signed with credentials by the person performing the hands-on treatment which include:
  • Notes describing treatment given and the patient’s response.
  • Written notes for each treatment and documentation for each charge.

All submitted documentation including initial evaluation, plan of care, treatment notes, progress notes and discharge summaries must be written and signed by the person performing the hands-on treatment of the patient. Therapist codes and stamps are not acceptable. Credentials such as PT or PTA must accompany the signature. Unsigned notes and documentation will not be accepted. When submitting documentation for review of isokinetic/computerized strength testing and ROM testing, the computerized printout must be included.

Appeals of Adverse Benefit Determinations 

One appeal, either expedited or standard, may be performed for medical necessity
non-certification determinations.

Expedited Appeal – An expedited appeal is available when there is an imminent or ongoing service requiring additional review of a non-certification determination. An appeal may be made by telephone, fax or email and include additional information to be reviewed. Notification of the results of the appeal is made by telephone to the provider within 72 hours of receipt of the request with written notification
to follow.

Standard Appeal – A standard appeal, due to a decision not to certify additional visits, must be made in writing by mail or fax by the provider. Include the patient’s medical record as needed for the review if not submitted previously to Blue Cross.
Appeal requests should be mailed/faxed to: 

Blue Cross and Blue Shield of Alabama 
Post Office Box 362025 
Birmingham, Alabama 35236 
Fax Number: 205-220-0941 
Telephone Number for Expedited Appeals: 205-220-7202

When requesting an appeal, additional information to support the medical necessity of the requested visits should be included. 

When a non-certification decision is made without a physician conversation, a peer-to-peer conversation may be requested by the ordering or supervising physician within three business days of the decision using the telephone number provided on the non-certification letter. If the original peer reviewer is not available, a peer alternate will be available to discuss the case. This does not count as an appeal. Any request beyond three business days of the decision is considered an appeal.

Preferred Physical Therapists Audits 

A major strength of Blue Cross in managing healthcare costs is our ability to audit Preferred Providers and affect changes in utilization practice habits. Our contractual arrangements give us the right to audit medical records of patients of Preferred PTs in order to objectively evaluate the coding, billing and practice patterns, as well as the completeness of their medical records.

An audit can be triggered by external referrals from members, group administrators, anonymous tips and even other physical therapists that feel that a particular physical therapist, group or facility is not in compliance with the program guidelines. An audit may also be triggered from internal claims and precertification data.

If an offsite audit reveals unusual practice patterns or billing procedures that result in overpayments, refunds are required from the physical therapist and the amount is returned to the groups whose members were affected by the incorrect practices. Any physical therapist having an unsatisfactory audit must immediately correct any problems. A follow-up audit will be performed to ensure that he/she is in compliance with the Preferred PT guidelines. A second unsatisfactory audit can result in the therapist being removed from the Preferred Physical Therapy Program. These cases are referred to the Physical Therapist Advisory Committee for review. This committee is composed of five geographically distributed Preferred Physical Therapists.

Blue Advantage^® PPO is provided by Blue Cross and Blue Shield of Alabama, an independent licensee of the Blue Cross and Blue Shield Association.