CurrentColorado Rocky Mountain Health PlansPolicy N/A

Physical and Occupational Therapy evaluation coding and modifier reimbursement

Defines reimbursement rules for PT/OT evaluations and related CPT/HCPCS modifier use for UnitedHealthcare Community Plan Medicaid products, and who may bill for these services.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPhysical and Occupational Therapy evaluation coding and modifier reimbursement

Policy CodePolicy N/A

Change TypeVersion recorded

Effective DateN/A

Next Review DateN/A

Key ActionReport GO/GP modifiers for CMS-designated always-therapy codes and use CQ/CO paired with GP/GO when services are furnished in whole or in part by PTA/OTA.

SourceLink

POLICY UPDATE CHANGES

Policy version change recorded on 2/10/2026.

Policy entry dated 7/30/2024 recorded in history.

97161-97168CPT evaluation codes addressed

May 1, 2020GO/GP modifier requirement effective

Jan 1, 2020CQ/CO modifier requirement effective

Texas excludedState exception

PT/OT Evaluation Coverage Rules

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PT/OT evaluation and modifier coverage criteria

Coverage and billing rules for PT/OT evaluations and modifier reporting for UnitedHealthcare Community Plan Medicaid.

Services billed on the CMS‑1500 form or electronic equivalent for UnitedHealthcare Community Plan Medicaid products.

ALL of the following

Physical and Occupational Therapists will be reimbursed for CPT codes 97161-97164 and 97165-97168.
Physical and Occupational Therapy Assistants (PTAs and OTAs) will not be reimbursed for CPT codes 97161-97164 or 97165-97168.

ALL of the following

UnitedHealthcare Community Plan will not reimburse Physical and Occupational Therapists or Physical and Occupational Therapy Assistants for CPT evaluation and management codes 99091, 99202-99499 or HCPCS code G2252.

ALL of the following

For dates of service on or after May 1, 2020, HCPCS modifiers GO and GP must be reported for codes CMS designates as 'always therapy' to indicate the discipline of the plan of care.

ALL of the following

For dates of service on or after January 1, 2020, HCPCS modifiers CQ and CO must be used when services are furnished In Whole or In Part by a PTA or OTA; CQ must be paired with GP and CO must be paired with GO.
CQ/CO modifiers do not apply to services furnished 'incident to' the services of physicians or nonphysician practitioners.
Texas is excluded from the PTA/OTA modifier requirement per state rules (Texas does not require CO or CQ on PTA/OTA services).

Codes, Modifiers, and Thresholds

Not Covered / Do Not ReportCPTNot Covered

99091	Remote monitoring management or evaluation — evaluation and management codes (not reimbursed for PT/OT)
99202-99499	Evaluation and management codes (not reimbursed for PT/OT)

Not Covered / Do Not ReportHCPCSNot Covered

G2252

Services typically reported using E/M codes (not reimbursed for PT/OT)

HCPCS Therapy ModifiersModifier

GO	Occupational therapy services — required for codes designated as always therapy; distinguish discipline of plan of care
GP	Physical therapy services — required for codes designated as always therapy; distinguish discipline of plan of care
CQ	Used for services furnished In Part by a PTA or OTA; must be paired with GP for PTA services
CO	Used for services furnished In Part by a PTA or OTA; must be paired with GO for OTA services

OTA/PTA 'In Part' threshold

OTA/PTA 'In Part' thresholdOTA/PTA minutes exceed 10% of total service minutes

Billing and Reporting Requirements

Billing Rule

Modifier reporting requirements (GO/GP and CQ/CO)

For dates of service on or after May 1, 2020, report HCPCS modifiers GO and GP on CMS-designated “always therapy” codes to indicate the discipline of the plan of care. For services furnished In Whole or In Part by a PTA or OTA (effective Jan 1, 2020), report CQ paired with GP and CO paired with GO on the same claim line. CQ/CO do not apply when services are furnished 'incident to' physicians or nonphysician practitioners. Texas is excluded from the PTA/OTA modifier requirement per state rules.

Report GO/GP for CMS-designated 'always therapy' codes for dates of service on/after 2020-05-01.
When services are furnished In Whole or In Part by a PTA/OTA (effective 2020-01-01), append CQ with GP and CO with GO on the service line.
Do not append CQ/CO for PTA/OTA services billed as 'incident to' a physician or nonphysician practitioner.
Texas is excluded from the CO/CQ PTA/OTA modifier requirement.

Note

Who may bill evaluation CPT codes (97161–97168)

Physical and Occupational Therapists will be reimbursed for CPT codes 97161–97164 and 97165–97168. Physical and Occupational Therapy Assistants will not be reimbursed for those evaluation CPT codes.

PTs and OTs: reimbursed for CPT 97161–97164 and 97165–97168.
PTAs and OTAs: not reimbursed for CPT 97161–97164 and 97165–97168.

Key Role and Term Definitions

Physical Therapist

TermPhysical Therapist

DefinitionAn individual who is licensed, if applicable, as a Physical Therapist by the State in which he or she is practicing.

ScopeApplies to individuals practicing in the state where licensed.

Occupational Therapist

TermOccupational Therapist

DefinitionAn individual who is licensed, if applicable, as an Occupational Therapist by the State in which he or she is practicing.

ScopeApplies to individuals practicing in the state where licensed.

Physical Therapy Assistant (PTA)

TermPhysical Therapy Assistant (PTA)

DefinitionAn individual who is licensed as a Physical Therapy Assistant (PTA), unless licensure does not apply, or is registered or certified, if applicable, as a PTA by the State in which he or she is practicing.

ScopeIncludes licensed, registered, or certified PTAs in the practicing state.

Occupational Therapy Assistant (OTA)

TermOccupational Therapy Assistant (OTA)

DefinitionAn individual who is licensed as an Occupational Therapy Assistant (OTA), unless licensure does not apply, or is registered or certified, if applicable, as an OTA by the State in which he or she is practicing.

ScopeIncludes licensed, registered, or certified OTAs in the practicing state.

In Whole

TermIn Whole

DefinitionAll the minutes of a service exclusive of the occupational therapist/physical therapist (as applicable).

UseIndicates the service was furnished entirely by the assistant portion excluded; used to determine modifier application.

In Part

TermIn Part

DefinitionA portion of a service separately from the part furnished by the occupational/physical therapist such that the minutes for that portion of a service furnished by the OTA or PTA exceed 10 percent of the total minutes for that service.

ImplicationTriggers use of assistant-related modifiers when assistant minutes exceed 10% of total service minutes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPhysical and Occupational Therapy evaluation coding and modifier reimbursement

Policy CodePolicy N/A

Change TypeVersion recorded

Effective DateN/A

Next Review DateN/A

Key ActionReport GO/GP modifiers for CMS-designated always-therapy codes and use CQ/CO paired with GP/GO when services are furnished in whole or in part by PTA/OTA.

SourceLink

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