Billing Rehabilitative and Habilitative Services

Billing Rehabilitative and Habilitative Services

11/4/2016

BlueCross BlueShield of South Carolina and BlueChoice HealthPlan will begin applying separate and distinct benefit limits for habilitative and rehabilitative services for dates of service on and after Jan. 1, 2017. This change is in compliance with the Notice of Benefit and Payment Parameters for 2016 rule issued in accordance with Affordable Care Act (ACA). This means that beginning with dates of service on and after Jan. 1, 2017, we will no longer have a combined visit limit for habilitative and rehabilitative services. Each of these services will now be counted separately. For example, today a patient may have 60 visits allowed in their benefit plan. After the first of the year, they may now have 30 habilitative services and 30 rehabilitative services available under their ACA-compliant health plan. It is important to identify which service is being rendered when billing to correctly count visits and ensure the patient’s benefits are applied appropriately.

Habilitative and rehabilitative services defined:

  • Habilitative services help a person keep, learn, or improve skills and functioning for daily living which have not developed.
  • Rehabilitative services help a person keep, restore, or improve skills and functioning for daily living which have been lost or impaired after an illness or injury, such as a car accident or stroke.

What you should do:

  • File with modifier SZ when billing habilitative services for the codes listed in the tables below. The SZ modifier distinguishes between habilitative and rehabilitative services. Appropriate use of the modifier will help reduce claims issues and adjustments related to habilitative services.
  • Review your current coding practices as it relates to the use of modifier SZ and the billing of habilitative and rehabilitative services.

Physical and Occupational Therapy Codes

97001 - 97006 97024 97116 97537 97750 G0152
97010 97026 97124 97542 97755 G0157 - G0160
97012 97028 97139 - 97140 97545 - 97546 97760 - 97762 G8990 - G8995
97014 97032 - 97036 97150 97597 - 97598 97799 S9129
97016 97039 97530 97602 4018F  
97018 97110 97532 - 97533 97605 - 97608 G0129  
97022 97112 - 97113 97535 97610 G0151 - G0152  

Speech Therapy Codes

92507 - 92508 92571 96105 G0161 G9174 - G9176 V5362
92521 - 92524 92577 96111 G8999 G9186 V5363
92526 92597 96116 G9158 S9128 4552F
92555 - 92557 96110 G0153 G9159 - G9164 S9152  

If you have questions about this bulletin, please send an email to provider.education@bcbssc.com or submit your question using the Provider Education Contact Form.