ModifiedAlliance HealthPolicy 10A

Outpatient Specialized Therapies

Policy governs coverage of outpatient specialized therapy evaluations and treatments (physical, occupational, speech-language, respiratory, audiology) for NC Medicaid beneficiaries receiving services outside inpatient hospital/rehab settings.

Policy Summary

PayerAlliance Health

PolicyOutpatient Specialized Therapies

Policy CodePolicy 10A

Change TypeMaterial revisions and additions (visit limits, PA clarification, coding added)

Effective DateAmended February 1, 2025

Next Review DateFeb 1, 2025

Key ActionObtain prior authorization before starting outpatient PT/OT/ST treatment and include a written evaluation within 3 months of the requested treatment start date.

SourceLink

POLICY UPDATE CHANGES

Amended visit limitations for beneficiaries aged 21 and older (effective December 1, 2023) and reorganized subsections including definitions and ordering practitioner requirements.

Updated annual maximum treatment visit counts to a total maximum of 30 treatment visits per calendar year for specified therapy categories.

Removed prior requirement that the first PA request be three visits and one month and clarified PA request limits (single PA can request up to 12 therapy treatment visits and six months).

Added comprehensive lists of covered CPT codes for audiology evaluation and treatment in Attachment A.

NC Medicaidapplicable program

3requires PA for PT/OT/ST

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30annual max per category

6authorization period (months)

25audiology PTA threshold (dB)

appliesEPSDT provision

Coverage Criteria and Clinical Requirements

General Criteria Covered

Covered when ALL of the following are met:

General medical necessity: The procedure, product, or service is individualized, specific, and consistent with the beneficiary's symptoms or confirmed diagnosis and not in excess of the beneficiary's needs.

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Safety and alternatives: The procedure, product, or service can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide.

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Not primarily for convenience: The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider.

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Covered Service Categories

Covered OST service categories:

Therapy types: Physical Therapy; Occupational Therapy; Speech-Language Therapy; Respiratory Therapy; Audiology Therapy.

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Ordering Practitioner Criteria

Services must be ordered by one of the following NC Medicaid enrolled practitioners:

Ordering practitioners: Medical Doctor (MD); Doctor of Osteopathic Medicine (DO); Doctor of Podiatric Medicine (DPM); Certified Nurse Midwife (CNM); Physician Assistant (PA); Nurse Practitioner (NP).

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Initial OST coverage conditions

Medicaid shall cover OST when the beneficiary meets service-specific criteria and prior authorization requirements:

Prior authorization and general requirement: Services (including PT, OT, ST) are covered when medically necessary, meet the applicable service-specific criteria, and prior authorization is obtained as required by Section 5.0. Evaluation visits do not require prior authorization.prior authorization when required

chunks 20-22,39,56

Speech-Language Therapy - Dysphagia: For oral, pharyngeal, or oropharyngeal phase dysphagia, documentation must show ONE listed deficit consistent with dysphagia (e.g., coughing/choking while eating or drinking; wet-sounding voice; suspected aspiration; frequent respiratory infections; muscle weakness affecting the pharynx; neuromuscular degenerative disease; oral function impairment affecting feeding) AND the deficit must be demonstrated by ONE of: VFSE/MBS, FEES, or a clinical feeding and swallowing evaluation.one deficit + one evaluation modality

chunks 22-23

Minority language speaker requirements

Speech-language therapy for minority language speakers:

Minority language speaker criteria: ALL of the following must be met: determination of the beneficiary's proficiency on the bilingual/English continuum (documented as bilingual-English proficient, limited English proficient, or limited in both languages); evaluation includes objective and subjective measures to determine higher proficiency language; all speech and language deficits are present in the language of highest proficiency; delivery of services is in the language of highest receptive proficiency; and when interpreters/translators are used, the SLP/audiologist must instruct the interpreter on purposes/procedures/goals, ensure the interpreter understands their role on each date of service, use the same interpreter consistently when possible, and supplement translated measures with observation or nonlinguistic measures.ALL

chunks 23-24

Pediatric speech-language criteria

Pediatric speech-language eligibility and severity classifications:

Language impairment severity classification: Classifies mild, moderate, and severe language impairment for beneficiaries birth to 20 years using standard score ranges, percentiles, language quotient ranges, or age-specific delay percentages; additional documentation of functional impairment in language components may be required.score ranges and percentiles as listed

chunks 25-26

Articulation/Phonology impairment classification: Defines mild, moderate, and severe articulation/phonology impairment by standard score ranges, percentiles, phonological process counts, percent consonant correct, and number/type of errors; treatment goals vary by age and eligibility uses total errors and intelligibility criteria.score ranges and phonological criteria as listed

chunks 27-29

Stuttering severity classification:

AAC coverage and therapy

AAC device and therapy coverage:

AAC device selection: Selection of augmentative and alternative communication (AAC) devices must meet ALL criteria specified in Clinical Coverage Policy 5A-1; devices must be dedicated speech-generating (digitized or synthesized).ALL

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AAC therapy program components: AAC therapy programs must include counseling; product dispensing; product repair and modification; AAC device treatment and orientation; prosthetic/adaptive device treatment and orientation; and speech and language instruction, all provided by a licensed SLP with AAC experience.ALL

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Reasons for additional AAC treatment: Authorization for additional AAC treatment may be provided for update of device, replacement of current device, significant revisions to device or vocabulary, or medical changes when an authorized AAC evaluation recommends a low- or high-tech system.

Audiology / Aural Rehabilitation criteria

Audiology (Aural Rehabilitation) coverage criteria:

Initiation criteria: Therapy may be initiated when the beneficiary demonstrates any degree/type of hearing loss on audiologic evaluation OR impaired/compromised auditory processing on central auditory test battery.any

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Deficits to initiate therapy: One or more of the following deficits must be present to initiate therapy: pure tone average >25 dB in either ear; Standard Score >1 SD below normal on standardized tests of language/audition/speech/auditory processing (documented via central auditory test battery); or <1-year gain in auditory/speech/processing skills during a 12-calendar month period.PTA>25 dB; Standard Score >1 SD below; <1-year skill gain

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Aural rehabilitation evaluation elements: Evaluation requires checking hearing aid/assistive device function and, via interview/observation/clinical testing, assessment of medical/audiological history; reception, comprehension and production of language; speech and voice production; perception of speech and non-speech stimuli; listening skills; speech-reading; communication strategies; and determination of specific measurable functional limitations.

Audiology (Aural Rehabilitation) — Covered with criteria

Covered when ALL of the following are met for Audiology Therapy (Aural Rehabilitation):

Audiology initiation

Triggering findings: Presence of any degree or type of hearing loss on audiologic evaluation OR impaired/compromised auditory processing on a central auditory test battery.
chunk 36
Deficits to initiate therapy: One or more deficits: (1) hearing loss with pure tone average >25 dB in either ear; (2) Standard Score >1 SD below normal on standardized tests of language/audition/speech/auditory processing; or (3) less than 1-year gain in skills during a 12-calendar month period.PTA>25 dB; Standard Score >1 SD below; <1-year skill gain
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Aural rehabilitation evaluation and content: Interventions aim to facilitate receptive and expressive communication and improve auditory processing; evaluation must include checking hearing aids/devices and assessment across specified domains with measurable functional limitations determined by the provider.

Initial and ongoing therapy — Covered with criteria

Covered when ALL of the following administrative and clinical requirements are met:

Evaluation requirement: Evaluation services are administration of an evaluation protocol (testing and clinical observation) resulting in a written evaluation report; evaluation visits may include immediate treatment and do not require prior authorization.

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Treatment plan requirement: A treatment plan must be established after evaluation and prior to treatment; plan duration must be ≤6 months and the plan plus evaluation/re-evaluation report must include start/end dates, diagnoses, rehabilitative/habilitative potential, specific measurable goals, skilled interventions/methodology, frequency, length of visits in minutes, and signature/credentials dated on or prior to the start date.treatment plan ≤6 months

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Order and renewal requirements: A verbal or written order is required prior to services; verbal orders must be recorded and countersigned by the physician within 60 days; orders are valid up to six months; treatment plans and goals must be reviewed/renewed at least every six months; prior approval is required prior to the start of treatment services (LEA IEP/IFSP/IHP/BIP/504 processes deemed to meet prior approval for LEAs).

Coverage criteria and visit limits

Covered when ALL of the following are met:

Prior authorization and documentation: Prior approval is required prior to the start of treatment services (required for beneficiaries under 21 and for beneficiaries 21 and older); initial written evaluation report must be completed within three months of the requested treatment start date; each reauthorization must document treatment efficacy and annual re-evaluation when continued treatment is requested. For LEAs, IEP/IFSP/IHP/BIP/504 are deemed to meet prior approval requirements.

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Authorization period limits: Authorization periods cannot exceed six calendar months; a single PA request may be obtained for up to 12 therapy treatment visits and six months.≤6 months; ≤12 visits per single PA request

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Visit limits for beneficiaries ≥21: Annual maximums per calendar year apply for beneficiaries 21 and older: 30 total combined PT/OT habilitative; 30 total combined PT/OT rehabilitative; 30 speech habilitative; 30 speech rehabilitative.

Therapy coverage and visit limit rules

Coverage and visit limits for beneficiaries 21 years of age and older are specified as annual and episodic allowances; prior authorization required for treatment visits.

Provider/order and PA: Services are covered when ordered by an MD, DO, DPM, CNM, PA, or NP and when prior authorization is received.

chunks 97-98

Annual therapy visits (>=21 yrs) - selected diagnoses: A beneficiary 21 years and older may have one (1) evaluation and a total of three (3) therapy treatment visits per calendar year if the beneficiary has a qualifying neurological or lymphedema diagnosis listed in Attachment A.

chunks 107-108

Episodic therapy visits - post-surgical or cast removal: A beneficiary 21 years and older may have episodic allowances of one evaluation and three therapy treatment visits within specified timeframes following qualifying neurosurgical or musculoskeletal surgical procedures, or within specified timeframes after cast/hardware removal or elimination of weight-bearing restrictions; a new qualifying procedure allows a new episode.timeframes vary per event; see Attachment A

Visit Limitations and Episodic Therapy

Beneficiaries 21 years of age and older: Visit limits and episodic allowances (as amended)

General annual rule: Any beneficiary 21 years and older may have one (1) therapy evaluation per calendar year. Annual therapy visits for certain diagnoses (neurological or lymphedema) may include one evaluation and three therapy treatment visits per calendar year; evaluation and treatment visits obtained prior to the beneficiary's 21st birthday count toward that calendar year.

chunks 108-109

Episodic therapy after surgery or cast removal: Within specified timeframes following neurosurgical or musculoskeletal surgical procedures (or cast/hardware removal or elimination of weightbearing/immobilization), beneficiary 21+ may have one evaluation and three therapy treatment visits for the episode; a new qualifying surgical procedure permits a new episode. Specific procedures and timeframes are listed in Attachment A.

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Joint replacement, prosthesis, hip fracture episodes: Within six months of discharge from inpatient services for joint replacement or hip fracture, or within two months of cast/hardware removal, beneficiary 21+ may have up to two evaluations and a total of eight therapy treatment visits; a new joint replacement, hip fracture, or new prosthesis allows a new episode.

Administrative coverage criteria

Billing and service delivery requirements:

Timed unit compliance: Timed units billed must meet CMS minute-per-unit thresholds as specified (1 unit = ≥8–22 minutes; 2 units = ≥23–37 minutes; etc.).see thresholds

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Telehealth modifier: Modifier GT must be appended to CPT/HCPCS codes to indicate services provided via interactive audio-visual telehealth; this modifier is not appropriate for virtual communications or remote patient monitoring.N/A

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Co-treatment billing rules: Co-treatment provided by OT and PT for a single beneficiary must not exceed the actual time spent; OT and PT must split time and bill only timed CPT codes. Co-treatment visits that include speech therapy must be at least 38 minutes in session length to bill both one speech event and one timed OT/PT unit; additional OT/PT timed units require an extra 15 minutes per additional unit.

EPSDT (Early and Periodic Screening, Diagnostic, and Treatment) requires coverage of medically necessary services for beneficiaries under age 21 to correct or ameliorate a condition. However, EPSDT does not obligate the state to provide services that are unsafe, ineffective, experimental or investigational, or that are not medical in nature or not generally recognized as accepted medical practice.

This policy does not address electrodiagnostic (EDX) evaluation services performed by licensed physical therapists. For coverage criteria and guidance for EDX studies, refer to Clinical Coverage Policy 1A-27, Electrodiagnostic Studies on the NC Medicaid website.

Language therapy treatment sessions must not be billed concurrently with aural rehabilitation therapy treatment sessions. Time billed for non-billable activities (for example, preparation, report writing, claims processing, documentation related to billing, or travel) also may not be billed and should not be included in billed session time.

Postoperative diagnostic analysis and programming of cochlear and auditory brainstem implant services are not addressed in this policy. For coverage criteria related to these services, see Clinical Coverage Policy 1A-4, Cochlear and Auditory Brainstem Implants.

When the type of treatment services a provider delivers are the same type of health-related services the beneficiary concurrently receives from the public school's special education program or an early intervention program, combined frequency of services must be documented and services may not be provided on the same day. The provider must document the frequency of school/early intervention services on the PA request and treatment plan.

If a beneficiary concurrently receives the same type of health-related services through a public school special education program or early intervention program, the provider must obtain and retain the current IEP or IFSP and document service frequency; such services may be limited and may not be provided on the same day as school/early intervention services.

Assessment services consist of administration of an evaluation protocol (testing and/or clinical observation) resulting in a written evaluation report. Assessment services do not include interpretive conferences, educational placement or care planning meetings, mass or individual screenings aimed at selection, or time for preparation/report writing, claims processing, documentation, or travel — those activities are not billable.

Medicaid does not guarantee approval of retroactive requests. Providers must obtain prior approval where required and follow NCTracks and the established prior authorization process; approval for medical necessity does not guarantee payment or beneficiary eligibility on the date of service.

Time spent for preparation, report writing, processing of claims, documentation regarding billing or service provision, or travel is not billable to the Medicaid program or other payers. These non-billable activities are considered part of the evaluation or treatment process and are incorporated into the rate per unit of service.

Services must be individualized, consistent with the beneficiary's symptoms or confirmed diagnosis, not in excess of needs, safe to furnish, and not primarily for convenience. Services that are not individualized, inconsistent with diagnosis/symptoms, excessive in scope, unsafe, or primarily for convenience are not covered.

Therapy services that are provided solely for maintenance (i.e., to maintain function without expectation of improvement) are not covered. Continued coverage requires documentation of rehabilitative potential and measurable progress.

Overt and consistent non‑compliance with the treatment plan by the beneficiary or by the parent/legal guardian may render continued services not medically necessary. Non‑compliance is a recognized discharge consideration and should be documented in the beneficiary record.

One discharge criterion is when the treatment plan no longer requires the services of a licensed therapist to address the targeted improvement(s). Other discharge triggers include achievement of goals, performance within age‑expected or normal limits, or lack of measurable progress despite appropriate interventions.

Coding, Units, and Attachments (Attachment A)

Attachment A: Claims-Related Informationmixed

See Attachment A

Claims-related coding and billing information (ICD-10-CM, CPT/PCS, Modifiers, Billing Units, Place of Service, etc.) referenced in Attachment A.

Attachment A: Claims-Related Information - Billing Guidancemixed

Refer to NCTracks Provider Claims and Billing Assistance Guide

Providers shall comply with NCTracks Provider Claims and Billing Assistance Guide and national coding guidelines for claim type and submission.

Telehealth CPT codes referencemixed

See Attachment A, Section C

CPT codes that may be billed via telehealth (telehealth-eligible codes are indicated in Attachment A, Section C).

Telehealth Guidance Referencemixed

Clinical Coverage Policy 1H

Telehealth, Virtual Communications and Remote Patient Monitoring guidance referenced for telehealth delivery criteria.

Attachment A surgical/CPT codes (examples shown)CPT

22532-22865	Musculoskeletal surgical procedure codes (added to Attachment A).
27126-27187	Musculoskeletal surgical procedure codes (added to Attachment A).
27236, 27244, 27248, 27253, 27254, 27258, 27259, 27269, 27280, 27282, 27284, 27286	Musculoskeletal CPT codes added to the 3-treatment chart.
27700, 27702	Moved to Musculoskeletal Surgical CPT Codes for 2 evaluations and 8 treatments.
31360, 31365	Codes added to Attachment A.

Attachment A diagnosis codes (examples shown)ICD-10

G46.0, G46.1, G46.2, G46.5, G46.6, G46.7, G46.8	ICD-10-CM Cerebrovascular Diseases added allowing max 3 treatment visits.
S06.1X0D, S06.1X0S, S06.1X1D, S06.1X1S, S06.1X2D, S06.1X2S, S06.1X3D, S06.1X3S, S06.1X4D, S06.1X4S, S06.1X5D, S06.1X5S, S06.1X6D, S06.1X6S, S06.1X7D, S06.1X7S, S06.1X8D, S06.1X8D, S06.1X9D, S06.1X9S	ICD-10-CM Intracranial injury codes added allowing max 3 treatment visits.

Timed billing unit definitionsmixed

timed-unit rules

1 unit: ≥8–22 minutes; 2 units: ≥23–37 minutes; 3 units: ≥38–52 minutes; 4 units: ≥53–67 minutes; 5 units: ≥68–82 minutes; 6 units: ≥83–97 minutes; 7 units: ≥98–112 minutes; 8 units: ≥113–127 minutes.

Timed billing unit regulatory referencemixed

CMS minute-per-unit rules

Timed units billed must meet CMS regulations as listed in Attachment A and policy history.

Audiology Evaluation CodesCPTCovered

92550	Audiology Evaluation
92551	Audiology Evaluation
92552	Audiology Evaluation
92553	Audiology Evaluation
92555	Audiology Evaluation
92556	Audiology Evaluation
92557	Audiology Evaluation
92567	Audiology Evaluation
92568	Audiology Evaluation
92570	Audiology Evaluation (1 unit = 1 test)

1–10 of 30

1/3

Audiology CPT Codes (duplicate group)CPTCovered

92550	Audiology Evaluation
92551	Audiology Evaluation
92552	Audiology Evaluation
92553	Audiology Evaluation
92555	Audiology Evaluation
92556	Audiology Evaluation
92557	Audiology Evaluation
92567	Audiology Evaluation
92568	Audiology Evaluation
92570	Audiology Evaluation (1 unit = 1 test)

1–10 of 30

1/3

Audiology Treatment CodesCPTCovered

92630	Audiology Treatment (1 unit = 1 event)
92633	Audiology Treatment (1 unit = 1 event)

Audiology Treatment Codes (duplicate)CPTCovered

92630	Audiology Treatment (1 unit = 1 event)
92633	Audiology Treatment (1 unit = 1 event)

Audiology CPT CodesCPTCovered

92550	Audiology Evaluation
92551	Audiology Evaluation
92552	Audiology Evaluation
92553	Audiology Evaluation
92555	Audiology Evaluation
92556	Audiology Evaluation
92557	Audiology Evaluation
92567	Audiology Evaluation
92568	Audiology Evaluation
92570	Audiology Evaluation (1 unit = 1 test)

1–10 of 30

1/3

Audiology CPT Codes (duplicate group) - shortCPTCovered

92652	Augmentative communication device assessment (1 event)
92653	Augmentative communication device coding (1 event)

Audiology Treatment Codes (duplicate)CPTCovered

92630	Audiology Treatment (1 unit = 1 event)
92633	Audiology Treatment (1 unit = 1 event)

Speech/Language Evaluation CodesCPTCovered

92521	Speech/Language Evaluation (telehealth eligible)
92522	Speech/Language Evaluation (telehealth eligible)
92523	Speech/Language Evaluation (2 areas assessed; telehealth eligible)
92524	Speech/Language Evaluation (telehealth eligible)
92551	Speech/Language Evaluation (telehealth ineligible)
92607	Speech/Language Evaluation (telehealth eligible)
92608	Speech/Language Evaluation (telehealth eligible)
92610	Speech/Language Evaluation (telehealth ineligible)
92612	Speech/Language Evaluation (telehealth ineligible)
92626	Speech evaluation (1 unit = 60 min) (telehealth ineligible)

1–10 of 12

1/2

Speech/Language Treatment Codes (evaluation overlap)CPTCovered

92507	Speech/Language Treatment (telehealth eligible)
92508	Speech/Language Treatment (telehealth ineligible)
92526	Speech/Language Treatment (telehealth eligible for oral motor only)
92609	Speech/Language Treatment (telehealth eligible)
92630	Hearing treatment (1 unit = 1 visit)
92633	Hearing treatment (1 unit = 1 visit)

Speech/Language Treatment CodesCPTCovered

92507	Speech/Language Treatment (telehealth eligible)
92508	Speech/Language Treatment (telehealth ineligible)
92526	Speech/Language Treatment (telehealth eligible for oral motor only)
92609	Speech/Language Treatment (telehealth eligible)
92630	Hearing treatment (1 unit = 1 visit)
92633	Hearing treatment (1 unit = 1 visit)

Speech/Language Evaluation Codes (duplicate)CPTCovered

92521	Speech/Language Evaluation (telehealth eligible)
92522	Speech/Language Evaluation (telehealth eligible)
92523	Speech/Language Evaluation (2 areas assessed; telehealth eligible)
92524	Speech/Language Evaluation (telehealth eligible)

OT/PT Evaluation and Treatment CodesCPTCovered

97165	OT Evaluation (1 unit = 1 event)
97166	OT Evaluation (1 unit = 1 event)
97167	OT Evaluation (1 unit = 1 event)
97168	OT Evaluation (1 unit = 1 event)
97750	OT/PT/Eval code (1 unit = 15 minutes)
29075	OT/PT Treatment (1 unit = 1 event)
29085	OT/PT Treatment (1 unit = 1 event)
29105	OT/PT Treatment (1 unit = 1 event)
29125	OT/PT Treatment (1 unit = 1 event)
29126	OT/PT Treatment (1 unit = 1 event)

1–10 of 45

1/5

OT/PT Codes - additional evaluationCPTCovered

97161	PT Evaluation (1 unit = 1 event)
97162	PT Evaluation (1 unit = 1 event)
97163	PT Evaluation (1 unit = 1 event)
97164	PT Evaluation (1 unit = 1 event)

OT/PT Codes - additional treatmentCPTCovered

29405	PT Treatment (1 unit = 1 event)
29425	PT Treatment (1 unit = 1 event)
29505	PT Treatment (1 unit = 1 event)
29515	PT Treatment (1 unit = 1 event)

Documentation and coding details

Reference for codes and billing guidanceSee Attachment A for exact ICD-10-CM, CPT/HCPCS/PCS codes, modifiers, billing units, and place of service; providers must follow NCTracks Provider Claims and Billing Assistance Guide.

Claim type and form guidanceProfessional (CMS-1500/837P) and Institutional (UB-04/837I) claim rules apply; file separate CMS-1500/837P transactions for evaluation and treatment services.

Correct Coding Initiative (CCI)Submit the comprehensive CPT code only; billing component CPTs in addition to a comprehensive code will result in denial per CCI guidance.

PA and billing NPI requirement

Prior Authorization, Documentation, and Billing Actions for Providers

Prior Authorization

Prior Authorization Required

Prior Authorization Required — Prior authorization (PA) is required before rendering outpatient specialized therapies (OT, PT, ST, audiology, etc.). For beneficiaries of all ages, obtain PA under the billing NPI that will appear on claims. Failure to obtain required prior authorization may result in claim denial.

PA requests must clearly indicate a licensed therapist is required.
PA for initial or continued treatment is medical approval only and does not guarantee payment or beneficiary eligibility on the date of service.
PA must be obtained under the same NPI that will be used to bill the service.

Denial Risk

Eligibility and Medical Necessity Triggers

Eligibility and Medical Necessity Triggers — Verify beneficiary enrollment in NC Medicaid and medical necessity at each visit. Services that are not individualized, not medically necessary, duplicate other covered services, or exceed the policy criteria may be denied.

Key Definitions

Independent Practitioner Provider (IPP)

DefinitionAn Independent Practitioner Provider (IPP) is an individual or group in private practice licensed to provide OST services, not employed by an institutional provider or a physician's office.

ScopeIPP provides outpatient specialized therapy services in private-practice settings and is distinct from institutional providers.

Reference to subsectionRefer to Subsection 6.1 for related definitions of specific therapist roles.

Dysphagia

Dysphagia definitionA swallowing disorder requiring documented findings consistent with dysphagia; findings must address at least ONE listed deficit (e.g., coughing/choking while eating or drinking; wet-sounding voice; frequent respiratory infections; known or suspected aspiration pneumonia).

Confirmation methods

Scope and Background

Outpatient Specialized Therapy (OST) includes evaluations, re‑evaluations, multidisciplinary evaluations, and treatment services delivered in non‑institutional settings for conditions requiring physical therapy, occupational therapy, speech‑language therapy, respiratory therapy, or audiology (aural rehabilitation). For beneficiaries under 21, EPSDT may allow exceptions to policy limitations when services are medically necessary to correct or ameliorate a condition.

Policy Revisions

02/01/2025policy_revisionLatest

Amended visit limitations for beneficiaries aged 21 and older (effective December 1, 2023); reorganized subsections, added Independent Practitioner Provider (IPP) definition, moved and clarified ordering practitioner requirements, added references to other CCPs and telehealth guidance, and required criteria to pertain to the beneficiary.

01/12/2020attachment_update

Attachment A updated (administrative/coding changes referenced in history).

Policy Summary

PayerAlliance Health

PolicyOutpatient Specialized Therapies

Policy CodePolicy 10A

Change TypeMaterial revisions and additions (visit limits, PA clarification, coding added)

Effective DateAmended February 1, 2025

Next Review DateFeb 1, 2025

Key ActionObtain prior authorization before starting outpatient PT/OT/ST treatment and include a written evaluation within 3 months of the requested treatment start date.

SourceLink

On This Page

Defines borderline/mild, moderate, and severe stuttering using stutters-per-minute or percent stuttered words, duration of dysfluencies, and presence of secondary characteristics; service level may be raised when combined severity indicators warrant it.

sw/m or percent stuttered words and duration

ALL elements present

CAPD evaluation and diagnosis: CAPD evaluation must be completed by an audiologist including communication, medical, and educational history and central auditory tests (auditory discrimination; temporal processing; dichotic speech; monaural low-redundancy; binaural interaction; electroacoustic; electrophysiologic measures). CAPD diagnosis requires scores ≥2 standard deviations below the mean on at least two central auditory tests and identification of measurable functional limitations.2 tests ≥2 SD below mean

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ALL evaluation elements

CAPD diagnosis requirement: CAPD diagnosis must be based on at least two central auditory tests with scores two standard deviations below the mean and documented functional limitations.2 tests ≥2 SD below mean

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orders valid up to 6 months; review every 6 months

Re-evaluation and discharge: When continued treatment is medically necessary, an annual re-evaluation must be documented in a written evaluation report; discharge occurs when goals are achieved, performance is within normal limits, the beneficiary is non-compliant, or the treatment plan no longer requires a licensed therapist.annual re-eval

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30 visits per category per calendar year

Speech-Language/Audiology visit ranges by severity: Speech-Language and Audiology visit ranges by severity are: Mild 6–26 visits; Moderate up to 46 visits; Severe up to 52 visits. Audiology sessions are 30–60 minutes, one to three times per week in six-month increments determined by severity and rate of change.

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Joint replacement/hip fracture/prosthesis episodes: Within six months of discharge from inpatient services for joint replacement or hip fracture, or within two months of cast/hardware removal or elimination of weight-bearing restrictions, or within six months of receipt of upper/lower extremity prosthesis, beneficiary 21+ may have up to two evaluations and a total of eight therapy treatment visits; a new qualifying event allows a new episode.6 months / 2 months per event

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Annual combined cap (historical reference): Previous guidance set a maximum of 27 therapy treatment visits per calendar year across all therapy disciplines combined; policy language has been updated to the 30-visit category caps above and episodic allowances remain as specified.27 visits/year (historical)

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CVA/TBI/SCI episodes: Within nine calendar months of discharge from inpatient services for CVA, TBI, or SCI, beneficiary 21+ may have up to three therapy evaluations and a total of 24 therapy treatment visits; a new documented occurrence with inpatient stay allows a new episode.

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Annual category maximums (amendment): Amended annual treatment visit limits effective December 1, 2023: a total maximum of 30 treatment visits per calendar year combined across OT/PT habilitative services; 30 across OT/PT rehabilitative services; 30 for speech habilitative; and 30 for speech rehabilitative services.30 visits per category per calendar year

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38 minutes minimum for combined speech+OT/PT billing

Non-billable activities: Time spent for preparation, report writing, processing of claims, documentation regarding billing or service provision, or travel is not billable to Medicaid or other payers; these activities are considered part of the evaluation/treatment unit rate.N/A

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Prior approval must be obtained under the billing NPI under which the service(s) will be billed.

Audiology pure tone average threshold

PTA thresholdPure tone average greater than 25 dB in either ear.

Context for audiology initiationPresence of any degree or type of hearing loss on audiologic evaluation can trigger audiology therapy when PTA > 25 dB.

Supporting criteriaAudiology initiation may also be based on impaired auditory processing on a central auditory test battery or other standardized test results.

Aural rehabilitation skill gain threshold

Skill-gain threshold for ARLess than a 1-year gain in auditory/speech/processing skills during a 12-calendar month period.

Use in initiationDocumented <1-year skill gain over 12 months is one of three deficits that may justify initiation of aural rehabilitation.

Documentation requirementSkill-gain must be documented in the beneficiary's evaluation or treatment records to support initiation/continuation of therapy.

Pure tone average (PTA)

Pure tone average (PTA)> 25 dB in either ear (pure tone average).

RolePTA >25 dB constitutes a deficit that may initiate audiology (aural rehabilitation) services.

Assessment basisDerived from audiologic (aural) rehabilitation evaluation results.

CAPD test score threshold

CAPD diagnostic thresholdDiagnosis requires scores ≥2 standard deviations below the mean on at least two central auditory tests.

Testing requirementCAPD evaluation must include specified central auditory tests (e.g., auditory discrimination, temporal processing, dichotic speech, monaural low-redundancy, binaural interaction, electroacoustic, electrophysiologic measures).

EvaluatorCAPD testing and diagnosis must be completed by an audiologist.

Speech-Language/Audiology impairment visit ranges

Mild impairment range6–26 visits per authorization period.

Moderate impairment rangeUp to 46 visits per authorization period.

Severe impairment rangeUp to 52 visits per authorization period.

PT/OT and Speech annual visit caps for ≥21

PT/OT habilitative annual cap (≥21)Total maximum of 30 treatment visits per calendar year combined across occupational and physical therapy habilitative services.

PT/OT rehabilitative annual cap (≥21)Total maximum of 30 treatment visits per calendar year combined across occupational and physical therapy rehabilitative services.

Speech annual caps (≥21)30 treatment visits per calendar year for speech therapy habilitative services and 30 for speech therapy rehabilitative services.

Authorization period maximum duration

Maximum authorization periodAuthorization period cannot exceed six calendar months.

PA single-request limitPrior Authorization (PA) can be obtained for up to 12 therapy treatment visits and six months in a single PA request.

Make-up session ruleMake-up sessions must occur within the same prior authorization period.

Initial evaluation timing

Evaluation report recencyA written evaluation report must be completed within 3 months of the requested treatment start date for prior approval requests.

Evaluation before treatmentEvaluation services result in a written evaluation report and the treatment plan must be established after evaluation and before treatment (except where evaluation includes immediate treatment as part of service).

PA submissionInitial PA requests must include supporting health records and the recent written evaluation to start approval process.

Timed billing unit thresholds

Timed-unit ranges (summary)Timed billing units map to specific minute ranges for units 1 through 8 per CMS rules (see detailed thresholds).

Reference to CMS-minute rulesProviders must follow CMS minute-per-unit rules when reporting timed CPT units.

Claim reportingBilling units are determined by the code(s) reported; report appropriate code(s) that determine billing units as listed in Attachment A.

Unit of service definitions

Unit-of-service examplesAttachment A lists unit-of-service for codes (examples: 1 event, 1 unit = 60 minutes for 92620/92626, each additional 15 minutes for add-on codes such as 92621/92627).

Evaluation vs treatment unitsSeparate CMS-1500/837P claim transactions must be filed for evaluation and treatment services; unit definitions vary by CPT/HCPCS code in Attachment A.

Audiology unit examplesAudiology codes 92620/92626: 1 unit = 60 minutes; add-on codes (92621/92627) billed per each additional 15 minutes; many audiology codes list 1 unit = 1 event.

Timed billing unit thresholds

1 unit≥8 through 22 minutes.

2 units≥23 through 37 minutes.

3 units≥38 through 52 minutes.

4–8 units4: ≥53–67; 5: ≥68–82; 6: ≥83–97; 7: ≥98–112; 8: ≥113–127 minutes.

Co-treatment billing minimum

Co-treatment minimum timeCo-treatment visits that include speech therapy and OT/PT must be at least 38 minutes in session length to bill both one speech event and one timed OT/PT unit.

OT/PT split billingOT and PT must split the time and bill only timed CPT codes; combined co-treatment billing must not exceed the actual time spent.

Additional timed unitsAdditional timed CPT units for OT/PT may be billed only when session length is extended by additional 15-minute increments.

Verify eligibility at each date of service.
Services must be individualized, targeted to documented deficits, and no more conservative/equally effective statewide alternative should exist.
Services duplicating school or early intervention program services may be denied without appropriate coordination/documentation.

Note

Approval Is Medical Only — Payment/Eligibility Not Guaranteed

Payment/Elegibility Not Guaranteed — Approval from the utilization review contractor is for medical approval only. Approval does not guarantee payment, nor does it ensure the beneficiary is eligible on the date services are rendered.

Retroactive PA requests are considered when Medicaid coverage is later approved, but Medicaid does not guarantee approval of retroactive requests.
Providers must still verify beneficiary eligibility at time of service even when PA is granted.

Documentation Required

Duplication with School / Early Intervention Services

Duplication with School or Early Intervention Services — When a beneficiary concurrently receives the same type of health-related service through a public school special education program (IEP) or an early intervention program (IFSP), the provider must obtain and retain a copy of the current IEP/IFSP and document combined frequency on the PA and treatment plan. Services should not be provided on the same day and combined services must meet medical necessity.

Obtain and retain the beneficiary's current IEP or IFSP when the services are the same type as school/early intervention services.
Document on the PA request and treatment plan the frequency at which the beneficiary receives the same type of service through the school/early intervention program.
Services may not be provided on the same day.

Billing Rule

CCI Bundling Denials — Use Comprehensive CPT Codes

Correct Coding Initiative (CCI) and Billing Denials — Bill using the most comprehensive CPT code that describes the service. Submitting component CPT codes in addition to a comprehensive (bundled) code will result in claim denial per CCI edits.

Refer to CMS Correct Coding Initiative guidance; only the comprehensive bundled code is paid.
Providers receive an EOB code indicating the component code cannot be billed in addition to the comprehensive code if submitted incorrectly.

Denial Risk

Prior Approval Must Use Billing NPI

NPI Match Requirement — Prior authorization must be obtained under the same National Provider Identifier (NPI) used to bill. PA requests under a different NPI than the billing NPI may result in denial.

Obtain PA under the billing NPI.
Claims billed under an NPI different from the NPI used for the PA may be denied.

Billing Rule

Co-treatment Billing Limits & Time Thresholds

Co-treatment Billing Limits and Time Thresholds — Co-treatment billing must not exceed the actual time spent with the beneficiary. OT and PT must split time and bill only timed CPT units appropriate to the time spent. When co-treatment includes speech therapy and OT/PT, the session must be at least 38 minutes to bill one event of speech therapy and one timed OT/PT unit.

Co-treatment claims cannot bill more total time than was actually spent in the visit.
OT and PT must allocate session minutes between disciplines and bill timed units accordingly.
To bill combined speech (event) plus one timed OT/PT unit, the session must be ≥38 minutes; additional timed units require additional 15-minute increments of session time.

Documentation Required

EPSDT — Documentation & Prior Approval

EPSDT Documentation and Prior Approval Note — For beneficiaries under age 21, EPSDT may allow exceptions to policy limits when services are medically necessary to correct or ameliorate a condition. If PA is required, being under 21 does not waive the PA requirement; providers must submit documentation showing EPSDT criteria are met and follow NCTracks and EPSDT guidance.

If PA is required for the service, beneficiaries under 21 must still obtain PA.
Submit supporting documentation that demonstrates how the requested services meet EPSDT criteria (correct/ameliorate a defect, illness, or condition).
Refer to NCTracks Provider Claims and Billing Assistance Guide and the NC Medicaid EPSDT provider page for additional guidance.

Prior Authorization

Prior Approval Submission & Required Documentation

Prior Approval Submission Documentation — Submit the PA request and ALL supporting health records and other records that demonstrate the beneficiary meets specific criteria. For initial PA, include an evaluation report completed within three months of the requested treatment start date; continued treatment requires documentation of efficacy and re-evaluation as specified.

Include the prior approval request and all health records supporting criteria in Subsection 3.2.
A written evaluation report must be completed within three months of the requested treatment start date for OT/PT and as specified for ST/AUD.
Each reauthorization must document treatment efficacy and include required re-evaluation documentation.

Documentation Required

Treatment Plan and Order Requirements

Treatment Plan Required Content and Orders — A treatment plan (plan of care) must be established after evaluation and before starting treatment. The treatment plan plus the evaluation or re-evaluation written report must include duration (start/end ≤6 months), diagnoses, rehabilitative potential, specific measurable goals, frequency and length of visits, skilled interventions, and the name/credentials/signature of the professional dated on or prior to the start of the plan. Verbal or written orders must be obtained prior to treatment and verbal orders must be countersigned by a physician within 60 days.

Treatment plan must include: start/end dates (≤6 months), discipline-specific diagnosis and related medical diagnoses, rehabilitative/habilitative potential, specific measurable goals, skilled interventions/methods, frequency, visit length in minutes, and provider name/credentials/signature dated on or prior to start.
Obtain verbal or written order prior to services; verbal orders must be documented with date and signature of the person receiving the order and countersigned by a physician within 60 calendar days.
Review and renew or revise treatment plans and goals at least every six months.

Documentation Required

Make-up Sessions — Documentation & Timing

Make-up Session Documentation Rules — Missed sessions may be rescheduled when medically necessary if completed within 30 calendar days of the missed visit and within the same prior authorization period. Make-up sessions must be documented as a separate date of service and must reference the missed date. When billing in timed units, do not add time from missed visits to other sessions in ways that change the treatment time specified on the treatment plan or PA.

Make-up sessions must occur within 30 calendar days of the missed date and within the same PA period.
Make-up sessions are billed as separate dates of service and the record must reference the missed date.
Do not aggregate missed session minutes into subsequent visits to exceed the time documented on the treatment plan or PA.

Billing Rule

Timed Units, Documentation, and Modifiers

Timed-unit Billing Documentation and Modifier Use — Timed units must meet CMS minute-per-unit rules when billing (1 unit = ≥8–22 minutes; 2 units = ≥23–37 minutes; 3 units = ≥38–52 minutes; etc.). Append applicable modifiers per guidance; use modifier GT for services provided via interactive audio-visual telehealth. Document session start/end and total timed minutes in the record.

Report billing units consistent with CMS regulations for minutes-per-unit.
Append modifier GT for interactive audio-visual telehealth services where applicable.
Document the duration of service (length of evaluation or treatment session in minutes) for each billed date of service.

Prior Authorization

Evaluation Recency Requirement for PA

Evaluation Recency for Prior Authorization — For PA requests, include a written evaluation report within three months of the requested treatment start date. When continued treatment is requested, annual re-evaluation and documentation of efficacy are required as specified by discipline.

Initial written evaluation report must be within three months of requested start date.
Annual re-evaluation is required for continued treatment and each reauthorization must document efficacy of treatment.
Include assessment summaries and test results in the evaluation and re-evaluation reports.

Documentation Required

Coding Specificity and Documentation

Coding Specificity and Documentation — Report ICD-10-CM and procedural codes to the highest level of specificity that supports medical necessity. Use current code editions and follow national coding guidelines. Bill using the most comprehensive CPT code that describes the service performed.

Use the current ICD-10-CM edition and code to the highest level of specificity.
Follow national coding guidelines and NCTracks Provider Claims and Billing Assistance Guide.
Bill the most comprehensive CPT code; avoid submitting component codes in addition to comprehensive (bundled) codes.

Billing Rule

Visit Sequence and Authorization Period Requirements

Visit Sequence Requirement — Episodic visit limits and annual visit limits must be applied in the required sequence: episodic visit limits must be expended prior to using annual visits when the episode of care occurs before annual visits. Adhere to authorization period limits (authorization periods cannot exceed six months) and visit limits described in the policy.

PA can be obtained for up to 12 therapy visits and six months in a single request; authorization periods cannot exceed six calendar months.
Episodic visit limits should be used before annual visit allotments when applicable.
Annual and episodic visit limits vary by discipline and are described in the policy.

Findings should be demonstrated via VFSE/MBS, FEES, or clinical feeding and swallowing evaluation as appropriate and documented in records.

Examples of deficitsExamples include coughing/choking, drooling with swallowing, changes in breathing when eating or drinking, masses on tongue/pharynx/larynx, or neuromuscular disease likely to affect swallowing.

Aural rehabilitation

Definition of aural rehabilitationInterventions to facilitate receptive and expressive communication for beneficiaries with hearing loss, aiming to improve, augment or compensate communication processes.

TargetsImproves auditory processing, listening, spoken language processing, auditory memory, and supports learning and daily activities.

Service componentsEvaluation includes checking hearing aid/assistive device function and assessing multiple domains (history, language reception/production, speech/voice, perception, listening, speech-reading, communication strategies).

Aural rehabilitation

Aural rehabilitation servicesServices that facilitate receptive and expressive communication, improve or compensate communication processes and auditory processing, and benefit learning and daily activities.

Evaluation elementsProvider must check hearing aids/devices and evaluate medical/audiological history, language, speech, perception, listening, speech-reading, and communication strategies; determine measurable functional limitations.

CAPD evaluation linkCAPD evaluation is part of aural rehabilitation when indicated and requires completion by an audiologist using specified central auditory tests.

Central Auditory Processing Disorder (CAPD) diagnosis

CAPD diagnostic criterionDiagnosis of Central Auditory Processing Disorder (CAPD) is based on scores ≥2 standard deviations below the mean on at least two central auditory tests.

InterpretationInterpretation is derived from performance across multiple tests; provider must determine measurable functional limitations for the beneficiary.

Functional deficits examplesFunctional deficits may include inability to hear conversational speech, understand classroom speech, localize sound, or process phonemes and suprasegmental aspects of speech.

Habilitative and Rehabilitative Services

Habilitative and rehabilitative definitionsHabilitative and Rehabilitative Services are defined per CMS glossary and 45 CFR § 156.115.

Application to visit capsDefinitions determine which annual caps apply (e.g., separate 30-visit caps for habilitative vs rehabilitative OT/PT and speech services for beneficiaries ≥21).

ReferenceSee CMS Glossary and 45 CFR § 156.115 for full definitions.

Concurrent school/early intervention services

Concurrent school/early intervention services ruleWhen a beneficiary concurrently receives the same type of health-related services as part of a public school special education program or early intervention program, services may not be provided on the same day by OST providers.

Documentation requirementObtain and retain a copy of the patient's current IEP or IFSP and document the frequency of school/early intervention services on the PA request and treatment plan.

ScopeApplies to services that are the same type of health-related services provided by the school or early intervention program.

Assessment services

Assessment services definitionAdministration of an evaluation protocol (testing and/or clinical observation) resulting in a written evaluation report; excludes interpretive conferences, educational placement or care planning meetings, and mass or individual screenings.

Treatment services definitionTherapeutic procedures addressing observed needs performed and evaluated by a qualified provider; includes family/caregiver instruction to facilitate carry-over; excludes consultation and maintenance/monitoring activities.

Documentation outcomeEvaluation protocols must generate a written evaluation report to support treatment and PA requests.

Treatment services

Treatment services definitionTherapeutic procedures addressing observed needs performed and evaluated by a qualified provider; includes family/caregiver instruction to facilitate carry-over.

ExclusionsTreatment services do not include consultation activities, objectives involving English as a second language, or treatment plans primarily dealing with maintenance/monitoring activities.

IndividualizationAll treatment services must be provided on an individualized basis (except group speech-language therapy as specified).

Independent Practitioner Provider (IPP)

IPP definition (alternate)An individual or group in private practice licensed to provide outpatient specialized therapy services, not through an institutional provider and not employed by a physician's office.

Effective date noteIPP term and related amendments noted in policy history effective December 1, 2023 (amendments recorded 02/01/2025).

UseIPP designation distinguishes private-practice providers from institutional or physician-employed providers for OST service delivery.

Timed unit

Timed unit definitionA timed unit maps to CMS minute thresholds: 1 unit = ≥8–22 minutes; 2 units = ≥23–37 minutes; continuing in ~15-minute increments up to 8 units.

Billing implicationsTimed units billed must meet CMS minute-per-unit rules and are used to determine the number of units reported on claims.

Reference to Attachment AAttachment A and policy specify minute ranges and unit mappings; follow CMS regulations when reporting timed units.

Telehealth modifier GT

Telehealth modifier GTAppend modifier GT to the CPT or HCPCS code to indicate services provided via interactive audio-visual telehealth.

Appropriate useModifier GT is not appropriate for virtual communications or remote patient monitoring; follow applicable modifier guidelines.

Provider responsibilityProviders must append GT and follow telehealth claims guidance when billing telehealth-eligible codes as noted in Attachment A.