13.6.7 Exceptions and Limitations

PARS that are provided in a residential setting are limited to 180 days from the first day of services and are sponsored by the CRS program. All services must be preauthorized.

Tier Base: A participant does not receive any core therapy services on a given day. The provider bills Tier Base for that day to indicate that the provider is being reimbursed only for the base services and that no core therapy services were provided. The CRS program does not expect that participants will be approved for Tier Base. The tier is provided to account for days of service that fall below the authorized tier.

Tier Base Plus: A participant receives a limited core therapy service of one- to three-quarter hours per day. The CRS program does not expect that participants will be approved for Tier Base Plus. The tier is provided to account for days of service that fall below the authorized tier.

Core Individual and Group Therapy: One hour of individual therapy or two hours of group therapy count as one hour toward a tier. The total number of hours applied to a tier equals the sum of the individual and group hours. For example, one hour of individual and one hour of group equals 1.5 hours total and is billed as Tier 1. One hour of individual and four hours of group equals three hours total and is billed as Tier 3. For group therapy, group size is limited to ten participants.

Billing Core Therapy Services: Two therapists cannot bill for the same period. Divide therapy units and time by the number of therapists delivering the service to determine the number of hours attributed to each. For example, if a physical therapist and an occupational therapist deliver one hour of individual therapy to a participant together, the therapy counts as one hour toward the tier. On the supporting documentation, the therapy is shown as .5 hours of physical therapy and .5 hours of occupational therapy. (The providers may split the hour differently, such as three-quarter hours of physical therapy and one-quarter hours of occupational therapy, if the sum does not exceed one hour. For staff qualifications, see Appendix B Post-Acute Rehabilitation Core Services – Modality and Staff Qualifications.

Billing for a partial week: If billing for fewer than seven calendar days, the billing guidelines for the maximum number of hours provided at the approved tier apply. For example, if a participant is approved for Tier 4, the sum must not exceed 28 hours, regardless of the number of days involved.

Copays: Providers bill a third party or the participant ’s insurance company for services. The CRS program pays the consumer’s required copay or coinsurance for the service. Tiered rates do not apply. However, the provider must still submit detailed billing information on the services delivered to the participant.

Day of Admission or Discharge: Admission and discharge days are handled the same as any other service day. If no core therapy services are delivered, the provider bills for Tier Base services. If core therapy services are delivered, the provider bills for the appropriate tier for the number of hours delivered, in accordance the prior authorization.

Therapeutic Passes: A therapeutic pass allows a participant to leave a residential facility unaccompanied by facility staff. Therapeutic passes are reviewed and incorporated into the participant’s plan of care by the treatment team. The purpose of the therapeutic pass is to facilitate a participant’s transition from a residential facility to their own home and the community. For example, a participant may go home for the weekend to practice skills learned and apply them to the home environment, go shopping with family members, or practice taking the bus or public transportation. While a participant is on therapeutic pass, staff members from the residential facility must be available to provide the participant, the participant’s family, or others who are supporting the participant with guidance and instruction, usually by phone as needed.

Within one day of the participant’s return to the facility, the facility team must review and address with the participant all of the issues identified while on the therapeutic pass. If the facility team determines that changes in the participant’s therapy services or ancillary services are required, a team member must notify the CRS counselor and schedule a follow up interdisciplinary team meeting. If the counselor and the interdisciplinary team approve, the facility team incorporates techniques into the participant’s therapy or ancillary services to address the issues.

Providers must document services provided and may bill for services rendered while the participant is at the residential facility on the same day as a therapeutic pass. For example, a participant has a pass scheduled to leave the facility from 11 a.m. to 5 p.m., but requires assistance for ADL’s, medications, and meals before and after the pass so, the provider may bill for this date. If the participant will be out of the facility for a 24-hour period with no services provided, the provider cannot bill for that time.