Does S9131 require prior authorization?

No, S9131 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for S9131?

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

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`S9131`, Physical therapy; in the home, per diem

HCPCS/CPT

Prior Authorization

No Prior Auth Required

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).

NUCCA assessment descriptions used in studies: objective x-ray views of the head and neck ("By using precise and objective x-ray views of the head and neck, mathematical measurement and analysis are made of the misalignment.") and clinical tests such as the supine leg check (leg length inequality), Anatometer (standing posture), Gravity Stress Analyzer, and hip calipers.

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).

6 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-0107, Chiropractic Services

AETNA-CPB-0665, Constraint-Induced Therapy

AETNA-CPB-0444, Early Intervention Programs

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S9131, Physical therapy; in the home, per diem