Does S8990 require prior authorization?

No, S8990 does not require prior authorization (medium confidence). Covered without prior authorization by at least one policy, though another does not cover it.

What is the Medicare reimbursement rate for S8990?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`S8990`, Physical or manipulative therapy performed for maintenance rather than

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization by at least one policy, though another does not cover it (medium confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Initial therapy evaluation/initial therapy visit report must include: "A statement of the individual's medical history; and A comparison prior level of function to current level of function, as applicable; and A description of the individual's functional impairment including its impact on their health, safety, and/or independence; and A clear diagnosis including the appropriate ICD-10 code; and Reasonable prognosis, including the individual's potential for meaningful and noteworthy progress; and Baseline objective measurements (current versions of standardized assessments), including a description of the individual's current deficits and their severity level which include: Current standardized assessment scores, age equivalents, percentage of functional delay, criterion-referenced scores, and/or other objective information as appropriate for the individual's condition or impairment"

If a medical condition prevents completion of standardized assessments: "The therapist provides in-depth objective clinical information using task analysis to describe the individual's deficit area(s) in lieu of standardized assessments" and "The therapist should include checklists, caregiver reports or interviews, and clinical observation."

Plan of Care (POC) must include: "Functional or physical impairment; and Short and long-term therapeutic goals and objectives: Treatment goals should be specific to the individual's diagnosed condition or functional or physical impairment; Treatment goals must be functional, measurable, attainable and time based; Treatment goals must relate to individual-specific functional skills and Treatment frequency, duration, and anticipated length of treatment session(s)"

Re-evaluations must be completed at least once every twelve months or more frequently based on state regulatory requirements and must include: "Date of last therapy evaluation; and Number of therapy visits authorized, and number of therapy visits attended; and Compliance to home program; and Description of the individual's current deficits and their severity level documented using objective data; and Objective demonstration of the individual's progress towards each treatment goal...; and An updated statement of the prescribed treatment modalities and their recommended frequency/duration; and A brief prognosis with clearly established discharge criteria; and An updated individualized POC must include updated measurable, functional, and time-based goals"

Treatment session notes must include: "Date of treatment; Specific treatment(s) provided that match the CPT code(s) billed; Accurate documentation of the length of treatment session; The individual's response to treatment; Skilled ongoing reassessment of the individual's progress toward the goals; All progress toward the goals in objective, measurable terms using consistent and comparable methods; Any problems or changes to the POC; Individual or caregiver involvement in and feedback about home program activities; Signature and date of the treating provider."

Key Coverage Criteria

Group therapy when there is a "Prescribing provider's order for group therapy" and an individualized treatment plan and required supervision/documentation are provided.
Feeding and swallowing evaluations when documentation includes required case history, medical/clinical records, physical exam, previous screening/assessments, collaboration with providers/caregivers and assessment results leading to one or more outcomes (e.g., diagnosis of swallowing disorder, determination of safest route of nutrition/hydration, recommendations for intervention/support).
Habilitation, rehabilitation, and maintenance therapy (occupational, physical, and speech) when medically necessary as defined by the member specific benefit plan and clinical criteria.
Rehabilitative services: "intended to improve, adapt, or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality."
Habilitation services: "health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for individuals with disabilities in a variety of inpatient and/or outpatient settings."
Maintenance therapy when appropriate to "prevent disease, promote health, and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition," and when plan/medical necessity criteria are met (i.e., when further clinical improvement can reasonably be expected or when warranted by member benefit language and clinical criteria).

12 Active Policies

CARELON-physical-therapy-occupational-therapy-and-speech-therapy-2024-04-14, Physical Therapy Occupational Therapy and Speech Therapy

UHC-POL-habilitative-services-outpatient-rehabilitation-therapy, Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech)

UHC-POL-manipulative-therapy, Manipulative Therapy

AETNA-CPB-0062, Burn Garments

BCBSIL-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services

BCBSMT-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services

BCBSNM-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services

BCBSOK-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services

UMR-POL-UMR-manipulative-therapy, Manipulative Therapy

SUREST-POL-SUREST-manipulative-therapy, Manipulative Therapy

CIGNA-CPG278, Chiropractic Care

CIGNA-CPG155, Occupational Therapy

`S8990`, Physical or manipulative therapy performed for maintenance rather than

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

S8990, Physical or manipulative therapy performed for maintenance rather than

Prior Authorization

Medicare Pricing

Documentation Required

Key Coverage Criteria

12 Active Policies

Related Codes

Have a follow-up question?

`S8990`, Physical or manipulative therapy performed for maintenance rather than