CurrentDell Children's Health PlanPolicy N/A

Synchronous Audio-Visual PT, OT, and ST Evaluation and Treatment Telehealth Services and Procedure Codes

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This policy governs reimbursement for physical therapy, occupational therapy, and speech therapy evaluations and treatment delivered through synchronous audio-visual telehealth, including consent, clinical appropriateness, documentation, billing modifiers, reimbursable codes, exclusions, and Texas practice requirements.

Policy Summary

PayerDell Children's Health Plan

PolicySynchronous Audio-Visual PT, OT, and ST Telehealth Reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFebruary 1, 2022

Next Review DateN/A

Key ActionAppend modifier 95 and the applicable discipline modifier GP, GO, or GN to eligible therapy claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Therapy disciplines covered

95Remote delivery modifier

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CurrentDell Children's Health PlanPolicy N/A

Synchronous Audio-Visual PT, OT, and ST Evaluation and Treatment Telehealth Services and Procedure Codes

Customize your policy alerts

Sign up for all dellchildrenshealthplan policy alerts

Know when dellchildrenshealthplan releases new policies or updates existing guidance.

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Policy Summary

PayerDell Children's Health Plan

PolicySynchronous Audio-Visual PT, OT, and ST Telehealth Reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFebruary 1, 2022

Next Review DateN/A

Key ActionAppend modifier 95 and the applicable discipline modifier GP, GO, or GN to eligible therapy claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Therapy disciplines covered

95Remote delivery modifier

Discipline modifiers

19Telehealth-excluded codes

ExcludedAudio-only delivery

Telehealth Coverage Criteria

Conditions for reimbursement of synchronous audio-visual therapy

A listed PT, OT, or ST evaluation, re-evaluation, or treatment service may be reimbursed through synchronous audio-visual telehealth when all applicable conditions are met.

ALL of the following

The service is one of the procedure codes listed as reimbursable for synchronous audio-visual telehealth, including the specified PT, OT, and ST evaluation, re-evaluation, and treatment services.
The rendering therapist determines that telehealth is clinically appropriate and complies with the applicable discipline's rules.
The client or the client's parent or legally authorized representative provides consent; verbal consent is permissible when documented in the client's medical record.
The claim includes modifier 95 to indicate remote delivery and the applicable therapy modifier: GP for physical therapy, GO for occupational therapy, or GN for speech therapy treatment claims.
Treatment notes document that remote delivery was clinically appropriate according to the rendering therapist's professional judgment.

Telehealth exclusions and in-person requirements

The following delivery methods and services are excluded from telehealth reimbursement or require in-person delivery.

ONE of

The PT, OT, or ST service is delivered by telephone or other audio-only technology; these services are not reimbursed.
The service uses a procedure code listed as not reimbursable when delivered by synchronous audio-visual or audio-only technology, including wheelchair assessment and training (97542); orthotic or prosthetic management and training (97760, 97761, 97763); traction (97012); electrical stimulation and other device-based modalities (97014, 97016, 97018, 97024, 97026, 97028, 97032, 97033, 97034, 97035); hydrotherapy (97036); aquatic therapy (97113); therapeutic massage (97124); manual therapy (97140); or unlisted rehabilitation services (97799).
The service is a specialized evaluation required for new complex rehabilitation technology, such as power mobility, adaptive seating systems, or augmentative communication devices; the appropriate physical therapist, occupational therapist, or speech-language pathologist must be physically present, and the evaluation must not be delivered by telehealth.

Reimbursable Services and Billing Codes

Physical therapy evaluations and re-evaluation reimbursable by synchronous audio-visual telehealthCPTCovered

97161	Physical therapy evaluation, low complexity
97162	Physical therapy evaluation, moderate complexity
97163	Physical therapy evaluation, high complexity
97164	Physical therapy re-evaluation

Occupational therapy evaluations and re-evaluation reimbursable by synchronous audio-visual telehealthCPTCovered

97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
97168	Occupational therapy re-evaluation

PT and OT treatment services reimbursable by synchronous audio-visual telehealthCPTCovered

97110	Therapeutic exercises
97112	Neuromuscular re-education
97116	Gait training
97150	OT or PT group therapy
97530	Therapeutic activities
97535	Self-care/home management training
97537	Community reintegration, used with other therapeutic procedure codes

Speech therapy evaluations, re-evaluation, and treatment reimbursable by synchronous audio-visual telehealthCPTCovered

S9152	Speech therapy re-evaluation
92507	Speech, language, voice, communication, or auditory processing disorder treatment
92508	Speech group therapy
92526	Swallowing/oral dysfunction treatment

Services not reimbursed when delivered by synchronous audio-visual or audio-only technologyCPTNot Covered

97542	Wheelchair assessment and training
97760	Orthotic management and training, initial encounter
97761	Prosthetic training of upper and/or lower extremity, initial encounter
97763	Orthotic/prosthetic management and/or training, subsequent encounter
97012	Traction
97014	Electrical stimulation, unattended
97016	Vasopneumatic device
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy

1–10 of 21

1/3

Telehealth and therapy discipline modifiersModifier

95	Modifier indicating remote delivery
GP	Required physical therapy treatment modifier
GO	Required occupational therapy treatment modifier
GN	Required speech therapy treatment modifier

Remote delivery modifier

Required modifierModifier 95

PurposeIndicates remote delivery

Applies toClaims for services delivered by synchronous audio-visual technology

Discipline modifiers

Physical therapyUse modifier GP on applicable physical therapy treatment claims

Occupational therapyUse modifier GO on applicable occupational therapy treatment claims

Provider Requirements and Risk Controls

Documentation Required

Document Telehealth Consent

Obtain documented consent before telehealth from the client, the client’s parent, or legally authorized representative (LAR). Verbal consent is permissible but must be recorded in the medical record; confirm that telehealth is safe and clinically appropriate, and involve a parent or caregiver when needed to support treatment.

Consent must be obtained from the client or the client’s parent/LAR.
Document verbal consent in the client’s medical record.
Confirm safety and appropriateness and arrange parent/caregiver participation when clinically needed.

Note

Assess Delivery Appropriateness and Accessibility

Select synchronous audio-visual telehealth or in-person delivery based on accessibility, person- and family-centered needs, clinical circumstances, and the client’s choice—not provider convenience. Texas Medicaid does not reimburse PT, OT, or ST delivered by telephone or other audio-only technology.

Key Terms

Synchronous audio-visual telehealth

DefinitionReal-time delivery of physical therapy, occupational therapy, or speech therapy services using audio-visual technology

Eligible disciplinesPhysical therapy, occupational therapy, and speech therapy

Not reimbursedTelephone or other audio-only delivery is not reimbursed

Legally authorized representative (LAR)

Who it includesThe client receiving services or the client's parent or legally authorized representative

Consent roleThe client or the client's parent or LAR provides consent for telehealth

Verbal consent

Policy Summary

PayerDell Children's Health Plan

PolicySynchronous Audio-Visual PT, OT, and ST Telehealth Reimbursement

Policy CodePolicy N/A

Change TypeNo material change

Effective DateFebruary 1, 2022

Next Review DateN/A

Key ActionAppend modifier 95 and the applicable discipline modifier GP, GO, or GN to eligible therapy claims.

SourceLink

On This Page

Speech therapyUse modifier GN on applicable speech therapy treatment claims

Defer to the person receiving services regarding the mode of delivery.

Ensure the selected modality is accessible and person- and family-centered.

Do not use audio-only telephone delivery as a reimbursable telehealth service.

Note

Confirm Clinical Appropriateness

For reimbursable synchronous audio-visual evaluation, re-evaluation, and treatment services, the rendering therapist must determine that telehealth is clinically appropriate and must follow the applicable rules for the relevant discipline.

Applies to PT, OT, and ST services authorized for synchronous audio-visual delivery.
Clinical appropriateness must be determined by the rendering therapist.

Billing Rule

Apply Telehealth and Discipline Modifiers

Use modifier 95 to identify remote delivery and append the applicable discipline modifier on every claim: GP for physical therapy, GO for occupational therapy, and GN for speech therapy.

Modifier 95 is required for remote delivery.
Use GP, GO, or GN as applicable to the therapy discipline.

Documentation Required

Document the Remote-Delivery Rationale

Treatment notes must document that remote delivery is clinically appropriate based on the rendering therapist’s professional judgment.

Include the remote-delivery rationale in the treatment note.
Tie the rationale to the rendering therapist’s professional judgment and the client’s clinical needs.

Denial Risk

Avoid Nonreimbursable Telehealth Services

Do not submit nonreimbursable services as synchronous audio-visual or audio-only telehealth. These include wheelchair assessment and training, orthotic or prosthetic management and training, traction, device-based modalities, aquatic therapy, massage, manual therapy, and unlisted rehabilitation services.

Nonreimbursable examples include 97542, 97760, 97761, 97763, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97113, 97124, 97140, and 97799.
Do not bill these services through either synchronous audio-visual or audio-only technology.

Denial Risk

Perform Complex Rehabilitation Technology Evaluations In Person

Specialized evaluations required for new complex rehabilitation technology must be delivered in person, with the physical presence of the appropriate PT, OT, or speech-language pathologist.

Examples include power mobility and adaptive seating systems and augmentative communication devices.
Do not deliver these specialized evaluations by telehealth.

Billing Rule

Follow Texas Licensure and Supervision Rules

Deliver telehealth within Texas licensure, discipline-practice, and supervision requirements for PT, OT, and speech-language pathology, using a two-way audio-visual platform when telehealth is permitted.

Follow current Texas Occupational Therapy Rules, Physical Therapy Rules, and Speech-Language Pathologists and Audiologists Administrative Rules.
Therapy assistants may provide telehealth and receive supervision only within the limits of the applicable discipline rules.
Consult the Texas Medicaid Provider Procedures Manual, Telecommunications Services Handbook, and applicable PT, OT, and Speech Therapy Handbooks for current requirements.

Verbal consent is permissible and should be documented in the client's medical record