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Rehabilitative Care services are defined as the coordinated use of medical, social, educational or vocational services, beyond the Acute Care stage of disease or injury, for the purpose of restoring, keeping, and/or improving the physical functional ability of a patient lost as a result of disease or injury so that the patient may independently carry out ordinary daily activities. These services may include physical therapy, occupational therapy, and speech therapy.
HabilitativeCareservices are defined as the coordinated use of medical, social, educational or vocational services, necessary to address a disabling health condition, to assist a Member in acquiring or improving skills and functioning necessary for daily living that the Member never acquired or possessed due to the disabling health condition.Services may include physical therapy, occupational therapy, and speech therapy.
In compliance with requirements of the Notice of Benefit and Payment Parameters for 2016 issued pursuant to the Patient Protection and Affordable Care Act (PPACA), Blue Cross & Blue Shield of Mississippi will apply separate and distinct benefit limits for Habilitative Care and Rehabilitative Care services for PPACA compliant individual and small group health plans (PPACA Blue Care for Kids, Blue Care, and Blue Health Savings for Individuals, Blue Care Group, Benefit Choice, and Blue Health Savings Small Group) beginning with dates of services on or after January 1, 2017.
In order to differentiate between Habilitative Care and Rehabilitative Care, the appropriate modifier(s) must be reported and appended to the CPT or HCPCS procedure code(s) that represent the service performed.
When billing for services rendered for Habilitative Care, the provider should report Healthcare Common Procedure Coding System (HCPCS) modifier ‘SZ’ or Current Procedural Terminology (CPT) modifier ‘96’ (Habilitative Services). The ‘SZ’ and ‘96’ modifiers indicates Habilitative Care services were performed. Usage of this modifier will ensure that services rendered for Habilitative Care services are separately identifiable. Services reported without modifier ‘SZ’ or ‘96’ will not be considered Habilitative Care services.
When billing for services rendered for Rehabilitative Care, the provider should report Current Procedural Terminology (CPT) modifier ‘97’ (Rehabilitative Services). The ‘97’ modifier indicates Rehabilitative Care services were performed. Usage of this modifier will ensure that services rendered for Rehabilitative Care services are separately identifiable.
Providers should report modifiers ‘SZ’ or ‘96’ (Habilitative Services) and ‘97’ (Rehabilitative Services) on both professional (CMS-1500) and outpatient facility (UB-04) claims. For professional claims submitted electronically, the modifier is coded in the SV1 segment. For facility claims, the modifier is coded in the SV2 segment. The modifier should be appended to each corresponding CPT/HCPCS code on the claim rendered for Habilitative and/or Rehabilitative Care.
**Note: The provider should report modifiers ‘SZ’, ‘96’ and/or ‘97’ respectively, on all Habilitative and Rehabilitative Care service claims submitted to BCBSMS regardless of Member’s benefit plan.
Blue Cross & Blue Shield of Mississippi will only apply separate and distinct benefit limits for Habilitative Care and Rehabilitative Care services for PPACA compliant individual and small group health plans (PPACA Blue Care for Kids, Blue Care, and Blue Health Savings for Individuals, Blue Care Group, Benefit Choice, and Blue Health Savings Small Group) beginning with dates of services on or after January 1, 2017.
However, modifiers ‘SZ’, ‘96’ and/or ‘97’ must be submitted on all Habilitative and Rehabilitative Care service claims submitted to BCBSMS regardless of Member’s benefit plan.
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11/1/2016: Policy developed.
1/4/2018: Policy name was changed from "Coding Policy for Reporting Habilitative Care Services" to "Coding Policy for Reporting Habilitative and Rehabilitative Care Services". New modifiers ‘96’ (Habilitative Services) and ‘97’ (Rehabilitative Services) were added.
12/3/2020-Reviewed; no guidelines or coding updates needed.
2016 Professional Edition, HCPCS Level II, page 101
2018 CPT Professional Edition
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