Trailblazer , the MAC J4 contractor has released a DRAFT Physical Medicine & Rehabilitation Outpatient LCD (local coverage determination). The draft LCD is posted as of October 30, 2009 for a 45 day comment period that ends December 14, 2009. According to Trailblazer:
This LCD establishes frequency limitations of 5 (15-minute) PT or OT services per day and 60 (15-minute) PT or OT services per month. Providers of PT/OT services must be aware however, that any service reported to Medicare, even when reported at a frequency within the following stated covered guidelines, may be denied if done so in association with medical review of the patient’s record. Likewise, providers of PT/OT services must understand that though Medicare will allow the following units of service, each service must be medically reasonable and necessary for the specific patient and his or her condition. Additionally, Medicare expects that the patient’s medical record will clearly demonstrate that medical necessity. Further, Medicare does not expect that maximum allowable services will be routinely necessary, necessary for multiple week periods, or necessary for the entirety of the patient’s course of treatment.
This LCD also include a procedure to diagnosis edit list (78 pages long).