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With the passing of the Affordable Care Act (ACA) in 2010, habilitative and
rehabilitative services and devices became one of the ten Essential Health
Benefits (EHB) required to be covered by health care plans. Effective January
1, 2017, federal regulations clarified how these benefits should be covered by
requiring parity in coverage limits for habilitative and rehabilitative
services and requiring separate visit limits for each.1
As a result of these new regulations, habilitative and rehabilitative
services must be tracked separately for all members to ensure visit limits are
not combined. Therefore, providers that submit claims for habilitative services
may need to make a change to their billing practices to support compliance with
these requirements.
How are habilitative and rehabilitative
services defined?
Federal regulations define these services as follows:
- Habilitative services: Health care services and devices
that help a person keep, learn, or improve skills and functioning for daily
living. Examples include therapy for a child who is not walking or talking at
the expected age. These services may include physical and occupational therapy,
speech-language pathology, or other services for people with disabilities in a
variety of inpatient and/or outpatient settings.
- Rehabilitative services:
Rehabilitative services,
including devices, are provided to help a person regain, maintain, or prevent
deterioration of a skill or function that has been acquired but then lost or
impaired due to illness, injury, or disabling condition.2
Billing requirements
When billing habilitative services on claims for AmeriHealth members,
providers should use the available HCPCS modifier SZ (Habilitative
Services). This billing requirement applies to claims for both
professional and outpatient facility services. Also note the following for
electronic claims:
- Professional claims: The modifier is coded in the SV1
segment.
- Facility claims: The modifier is coded in the SV2
segment.
Without the SZ modifier, the service will be considered rehabilitative;
however, if providers use the modifier appropriately, AmeriHealth can track
habilitative and rehabilitative services separately and comply with EHB
requirements of the ACA regulations.
Note: The HCPCS code modifier SZ was created in 2014, so some
offices may already bill with this modifier for habilitative services
claims.
For more information
For more information about habilitative and rehabilitative services, review
Medical Policy #10.03.01g: Physical Medicine, Rehabilitation, and Habilitation
Services. To view this policy, visit our Medical Policy Portal and select Accept and Go
to Medical Policy Online. Then select the Commercial tab and type
the policy name or number in the Search field.
1See the regulation at 45 CFR ? 156.115.
2See preamble in the 2016 Notice of Benefit
and Payment Parameters (80 FR 10749).
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