Does S9129 require prior authorization?

No, S9129 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for S9129?

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

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`S9129`, Occupational therapy, in the home, per diem

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation that 'The burn is of documented significance to place the member at risk of a post-burn contracture.'
Documentation that 'The burn garment and physical and occupational therapies are being used with the intent of preventing the need for skin grafting or contractures as a result of hypertrophic scarring.'

When billing covered HCPCS codes, documentation must support that the 'selection criteria are met' (i.e., medical necessity criteria above) and include relevant ICD-10 burn diagnosis codes (T20.00x+ - T26.92x+; T30.0 - T32.99) as appropriate.

Clinical documentation should include burn location(s) and severity, risk for contracture, treatment plan (use of pressure garment and PT/OT), and physician authorization/order (primary care physician and/or treating specialist).

Documentation that the child meets an eligible condition per state-defined criteria for developmental delay (medical/diagnostic documentation of developmental delay or high risk).

Key Coverage Criteria

Aetna considers burn garments and associated physical and occupational therapy medically necessary when all of the following criteria are met:
The burn is of documented significance to place the member at risk of a post-burn contracture;
The burn garment and physical and occupational therapies are being used with the intent of preventing the need for skin grafting or contractures as a result of hypertrophic scarring;
The burn garment is authorized by the primary care physician and/or the treating specialist.
ICD-10 codes covered if selection criteria are met: T20.00x+ - T26.92x+ T30.0 - T32.99 (Burns).
HCPCS codes covered if selection criteria are met: A6501, A6502, A6503, A6504, A6505, A6506, A6507, A6508, A6509, A6510, A6511, A6512, A6513 (Compression burn garments and compression burn mask, custom fabricated).

5 Active Policies

ANTHEM-CG-REHAB-12, Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology

ANTHEM-CG-MED-23, Home Health

AETNA-CPB-0062, Burn Garments

AETNA-CPB-0444, Early Intervention Programs

AETNA-CPB-0250, Occupational Therapy

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S9129, Occupational therapy, in the home, per diem