CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Payment Policy: Physical and Occupational Services

Defines Blue Cross Blue Shield of Rhode Island coverage for physical therapy (PT), occupational therapy (OT), and assistant-delivered services (PTA/OTA), including covered CPT/OMT codes and coding/modifier requirements for applicable commercial and Medicare Advantage products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPayment Policy: Physical and Occupational Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/01/2015

Next Review DateN/A

Key ActionDocument and maintain a plan of care with short- and long-term goals, measurable objectives, frequency/duration, and expected improvement timeframe.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 hrtypical PT/OT session length

60 daysexpectation for improvement

Multiplecovered procedure codes

4OMT codes listed

2017-2024publication history

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Coverage Criteria

General coverage criteria

Covered when ALL of the following are met

Functional impairment and purpose: PT and OT services are covered when performed to meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or therapeutic intervention.

Benefit variability: Benefits may vary between groups/contracts; refer to the Subscriber Agreement for applicable physical and occupational benefits/coverage.

Qualified providers include MD, DO, APP (physician assistant, nurse practitioner, clinical nurse specialist), PT, OT, and PT/OT assistants (PTA/OTA) who act at the direction and under the supervision of the treating physical or occupational therapist and in accordance with state law. Assistants may not provide evaluation services or make clinical judgments; assistant‑delivered services must be billed with the required modifiers to identify the discipline and the assistant.

The following athletic training evaluation CPT codes are not covered: 97169 (Athletic training evaluation, low complexity), 97170 (Athletic training evaluation, moderate complexity), 97171 (Athletic training evaluation, high complexity), and 97172 (Re-evaluation of athletic training evaluation).

This portion of the document does not list any additional explicit clinical exclusions beyond the coding exclusions noted elsewhere; refer to the member's Subscriber Agreement for plan‑specific benefit limitations and to the policy references for further context.

Services determined to be not medically necessary or that are non‑covered benefits may result in coverage denial and potential member financial liability unless the member was informed and provided prior written agreement to proceed at their own expense; consult participation and subscriber agreements for applicable provisions.

Coding and Procedure Codes

Covered CPT/HCPCS CodesCPTCovered

97127	Therapeutic interventions that focus On cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity, direct (one-on-one) patient contact.
97161	Physical therapy evaluation: low complexity.
97163	Physical therapy evaluation: high complexity.
97164	Re-evaluation of physical therapy (this code is not separately reimbursed).
97165	Occupational therapy evaluation, low complexity.
97166	Occupational therapy evaluation, moderate complexity.
97167	Occupational therapy evaluation, high complexity.
97010	Application of a modality to 1 or more areas: hot or cold packs.
97012	Application of a modality to 1 or more areas; traction, mechanical.
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended).

1–10 of 43

1/5

Not covered codesCPTNot Covered

97170	Athletic training evaluation, moderate complexity.
97169	Athletic training evaluation, low complexity.
97171	Athletic training evaluation, high complexity.
97172	Re-evaluation of athletic training evaluation.

Osteopathic Manipulative Treatment (OMT)CPTCovered

98925	Osteopathic manipulative treatment (OMT) 1-2 body regions involved.
98926	Osteopathic manipulative treatment (OMT) 3-4 body regions involved.
98927	Osteopathic manipulative treatment (OMT) 5-6 body regions involved.
98928	Osteopathic manipulative treatment (OMT) 7-8 body regions involved.
98929	Osteopathic manipulative treatment (OMT) 9-10 body regions involved.

OMT CPT CodesCPTCovered

98925	Osteopathic manipulative treatment (OMT) 1-2 body regions involved.
98926	Osteopathic manipulative treatment (OMT) 3-4 body regions involved.
98927	Osteopathic manipulative treatment (OMT) 5-6 body regions involved.
98928	Osteopathic manipulative treatment (OMT) 7-8 body regions involved.
98929	Osteopathic manipulative treatment (OMT) 9-10 body regions involved.

E/M CPT Codes (referenced)CPT

99091	Evaluation and Management code referenced in guidance (per CPT ranges cited).
99202-99499	Range of E/M CPT codes referenced for reporting guidance.

Expectation for improvement timeframe

Expectation for improvement timeframeSignificant functional improvement expected within 60 days of the initial visits (typical plan-of-care timeframe)

Plan of care requirementPlan of care must include short- and long-term goals, measurable objectives, frequency/duration, and specific modalities/exercises

Provider Actions & Billing Requirements

Prior Authorization

Prior Authorization Required

Not applicable.

Documentation Required

Plan of Care Documentation

The documentation in the plan of care for physical and occupational therapy should include: statements of short-term and specific long-term goals; establishment that the patient needs the unique skills of the practitioner to reach goals; measurable objectives; a reasonable estimate of when the goals will be reached (typically an expectation of significant functional improvement within 60 days of the initial visits); the frequency and duration of treatment; and the specific modalities and exercises to be used in treatment. The plan of care should be updated as the patient’s condition changes.

Documentation Required

Documentation for OMT and Separate E/M

Background

Physical therapy (PT) treats disease or injury using interventions such as therapeutic exercise and other modalities to improve posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, activities of daily living, and to alleviate pain. These services are intended to restore or improve functional performance related to the patient’s condition.

Definitions

Habilitative services — definition and examples.

DefinitionHabilitative services: healthcare services that help a person learn or improve skills and functioning for daily living (e.g., therapy for a child not walking or talking at the expected age)

Included disciplinesMay include physical therapy, occupational therapy, speech and other services delivered in inpatient and/or outpatient settings

PurposeFocused on teaching or improving skills and functioning for people with disabilities rather than restoration after loss of function

OMT CPT codes 98925–98929 — number of body regions involved

98925Osteopathic manipulative treatment (OMT) — 1–2 body regions involved

98926

Revision History

2024Provider UpdateLatest

Policy updated and published in a Provider Update (2024).

2023-02Provider Update

Policy included in Provider Update published February 2023.

2020-01Provider Update

Policy included in Provider Update published January 2020.