CurrentColorado Rocky Mountain Health PlansPolicy CS161FL.M

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) - Site of Service (for Florida Only)

Defines medically necessary site-of-service expectations for outpatient speech, occupational, and physical therapy in Florida, applying to UnitedHealthcare Community Medicaid Plans of Florida and guiding when hospital outpatient sites are appropriate versus free-standing non-hospital facilities.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) - Site of Service (for Florida Only)

Policy CodePolicy CS161FL.M

Change TypeDefinition updateminor reference updates

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionFollow the companion Habilitation and Rehabilitation Therapy policy for visit-level prior authorization and documentation demonstrating medical necessity.

SourceLink

POLICY UPDATE CHANGES

Updated definition of 'Medically Necessary or Medical Necessity'.

Updated References section to reflect the most current information.

Florida-onlyapplicability

Speech/OT/PTtherapy types

60+reference codes

06/01/2026effective

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Site-of-Service Coverage Criteria

General site-of-service criteria

Site-of-service coverage when ALL of the following are considered:

Site-of-service decision factors: Therapy sessions must be Medically Necessary, including cost effective; consider state Medicaid contract, any federal or state requirements, geographic availability of an in-network provider, and free-standing clinic/facility capability to accommodate all necessary services.

From Coverage Rationale and Instructions for Use.

Exceptions allowing hospital outpatient site

Hospital outpatient site may be appropriate when ANY of the following apply:

When hospital outpatient site appropriate: The procedure or specialized therapist training is not available at a free-standing non-hospital facility; care is part of a Comprehensive Care Management clinic visit for conditions such as cleft lip and palate, paraplegia, quadriplegia, or traumatic brain injury; or care is for immediate post-amputation, major multiple trauma, postacute stroke, or severe burn injury.

Examples listed in Coverage Rationale; 'Comprehensive Care Management' defined in Definitions.

Physical or manipulative therapy performed for maintenance rather than restoration is identified by HCPCS code S8990 and is noted separately in this policy. The emphasis of coverage is on medically necessary restorative therapy; services billed with S8990 indicate maintenance intent and may not meet the policy's coverage intent for restorative, medically necessary therapy.

Services that are provided primarily for the convenience of the recipient, the recipient’s caretaker, or the provider are not considered Medically Necessary under this policy. Medical necessity requires care to be individualized, consistent with diagnosis, not excessive, reflective of safe service levels, and not furnished mainly for convenience.

CPT / HCPCS / S / G Code Listings

Speech therapy CPT codes (part 1)CPT

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals.
92521	Evaluation of speech fluency (e.g., stuttering, cluttering).
92522	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria).

Speech and modality CPT codes (part 2)CPT

92523	Evaluation of speech sound production; with evaluation of language comprehension and expression.
92524	Behavioral and qualitative analysis of voice and resonance.
92526	Treatment of swallowing dysfunction and/or oral function for feeding.
92609	Therapeutic services for the use of speech-generating device, including programming and modification.
92610	Evaluation of oral and pharyngeal swallowing function.
96105	Assessment of aphasia with interpretation and report, per hour.
97012	Application of a modality; traction, mechanical.
97014	Application of a modality; electrical stimulation (unattended).
97016	Application of a modality; vasopneumatic devices.
97018	Paraffin bath.

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Therapy evaluation and procedure CPT codesCPT

97039	Unlisted modality (specify type and time if constant attendance).
97110	Therapeutic exercises, each 15 minutes.
97112	Neuromuscular reeducation, each 15 minutes.
97113	Aquatic therapy with therapeutic exercises.
97116	Gait training (includes stair climbing).
97139	Unlisted therapeutic procedure.
97140	Manual therapy techniques, each 15 minutes.
97150	Therapeutic procedure(s), group (2 or more individuals).
97161	Physical therapy evaluation: low complexity.
97162	Physical therapy evaluation: moderate complexity.

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HCPCS / S codes / G codesHCPCS

G0281	Electrical stimulation (unattended), to one or more areas, for chronic Stage III/IV pressure ulcers and similar wounds as part of therapy plan of care.
G0283	Electrical stimulation (unattended) for indications other than wound care, as part of a therapy plan of care.
S8948	Application of a modality; low-level laser; each 15 minutes (constant attendance).
S8990	Physical or manipulative therapy performed for maintenance rather than restoration.
S9129	Occupational therapy, in the home, per diem.
S9131	Physical therapy, in the home, per diem.
S9152	Speech therapy, re-evaluation.

inv-09: Wound healing after conventional care — No measurable signs of healing after 30 days

ThresholdNo measurable signs of healing after 30 days of conventional care

Related HCPCS codeG0281 — Electrical stimulation (unattended) for chronic Stage III/IV pressure ulcers and similar wounds as part of a therapy plan of care

ContextApplies to chronic Stage III/IV pressure ulcers, arterial, diabetic, and venous stasis ulcers not showing measurable healing after 30 days of conventional care

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization Referenced

Prior authorization requirements and criteria for therapy visits are addressed in the separate Habilitation and Rehabilitation Therapy policy. Providers must refer to that policy for the specific prior authorization process, required clinical criteria, and any visit limits or timeframes that apply.

See: Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for Florida Only)

Note

Site‑of‑Service Determination Factors

Decision about the appropriate site of service will consider the state Medicaid contract, any applicable federal or state requirements, the geographic availability of an in‑network provider, and the capability of the free‑standing clinic/facility to accommodate all necessary services. An outpatient hospital site may only be appropriate when specialized procedures or therapist training are not available in a non‑hospital setting or when part of comprehensive care management for complex conditions.

Factors: State Medicaid contract; federal/state requirements; network availability; facility capability
Hospital outpatient site appropriate when specialized services or training unavailable in free‑standing facility or when linked to comprehensive care management (e.g., cleft lip/palate, paraplegia, quadriplegia, traumatic brain injury)

Background

Outpatient speech, occupational, and physical therapy are generally appropriate to provide safely in free-standing non-hospital facilities. Hospital outpatient or inpatient sites are reserved for situations requiring specialized services, comprehensive care management for complex conditions (for example, cleft lip/palate, paraplegia/quadriplegia, or traumatic brain injury), or acute needs such as immediate post-amputation care, major multiple trauma, postacute stroke, or severe burns. Documentation must demonstrate that the level of care cannot be effectively and safely furnished in a non-hospital setting and meets the definition of Medically Necessary in this policy.

Key Definitions

inv-15: Comprehensive Care Management — care management for complex, chronic conditions including systematic assessment and system-based approaches (CMS, 2025).

DefinitionCare management for complex, chronic conditions including systematic assessment of medical, functional, and psychosocial needs; system-based approaches for timely receipt of preventive care; medication reconciliation with review of adherence and interactions; and oversight of patient self-management (CMS, 2025).

Examples of activitiesMedication reconciliation, preventive care coordination, oversight of self-management

ScopeIntended for complex, chronic conditions requiring multi-domain assessment and system-based care approaches

inv-16: Medically Necessary or Medical Necessity — definition and required characteristics of services (life/illness/pain protection, individualized, not experimental, no equally effective less costly alternative, not for convenience).

Primary requirementServices must protect life, prevent significant illness or disability, or alleviate severe pain (requirement applies to recipients age 21+).

Policy Revision History

2026-06-01definition_updateLatest

Updated definition of 'Medically Necessary or Medical Necessity' to clarify criteria for services including protection of life, prevention of significant illness or disability, individualization, conformity with professional standards, safety, and avoidance of convenience-based services.

2026-06-01archival

Archived prior policy version CS161FL.L as part of the June 1, 2026 revision.