Evidence-based falls evaluations are encouraged by Medicare. Although the importance of falls evaluations has been recognized by the research community for many years, there has been a lag in the translation of this knowledge to the clinical community. Falls evaluations are components of existing quality improvement efforts for Medicare Part A providers.
Other than the potential coverage of 'falls risk' as part of “the review of individual beneficiary’s functional ability and level of safety”, contained in the Medicare Initial Preventive Physical Exam (IPPE), the routine evaluation of Medicare beneficiaries for their risk of falls is not part of the Medicare benefit. While no defined benefit exists for determining the risk of falls, individuals with a history of falls often have impairments of body structure/function that could potentially require the skills of a physical therapist and/or occupational therapist. Palmetto GBA has, therefore, included V15.88 (history of falls) in the final policy (see list below) to reflect this potential. While claims containing V15.88 would still require the addition of another covered ICD-9-CM code to specify the impairment of structure/function and/or activity limitation (e.g., ICD-9-CM 438.4 monoplegia of lower limb; ICD-9-CM 781.2 abnormality of gait), inclusion of the V15.88 code will help communicate the coverage available and help promote communication of reasonable and necessary physical therapy and/or occupational therapy interventions.
To allow for falls evaluations in Part A environments, Palmetto GBA has therefore included the V15.88 code in its Part A Local Coverage Determinations (LCDs) addressing North Carolina Outpatient Physical Therapy (PT) (L1166) and South Carolina Outpatient Physical Therapy (PT) (L10214) and South Carolina Outpatient Occupational Therapy (OT) (L12642) and North Carolina Outpatient Occupational Therapy (OT) (L1149). The code will also be included in Physical Therapy for Home Health PT (L282) and Home Health-Occupational Therapy OT (L12643) LCDs.
Palmetto GBA invites you to review the Part A Outpatient PT and OT LCD, as well as the Home Health PT and OT LCD on the Palmetto GBA Web site at www.PalmettoGBA.com/anc (for North Carolina Part A providers), www.PalmettoGBA.com/asc (for South Carolina Part A providers) and www.PalmettoGBA.com/rhhi (for home and hospice providers).