CurrentMolina HealthcarePolicy N/A

Physical and Occupational Therapy Initial Evaluation Reimbursement

Governs Molina Healthcare reimbursement and billing guidance for initial physical therapy (PT) and occupational therapy (OT) evaluation services for Molina members; affects providers billing PT/OT evaluation codes.

Policy Summary

PayerMolina Healthcare

PolicyPhysical and Occupational Therapy Initial Evaluation Reimbursement

Policy CodePolicy N/A

Change TypeTemplate updates / minor revisions

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit charges for an initial therapy evaluation on multiple dates of service; if the evaluation spans multiple days, bill as a single unit on the date the evaluation is concluded.

SourceLink

POLICY UPDATE CHANGES

Updated template and verified links.

Updated template and verified links (08/06/2025).

Updated Template (08/21/2025).

1unit billing requirement when evaluation spans multiple days (bill as single unit)

3states with explicit exceptions listed

2023-09-08policy initial creation date

2025-08-21most recent revision date

PT/OT Initial Evaluation Coverage

Policy Summary

PayerMolina Healthcare

PolicyPhysical and Occupational Therapy Initial Evaluation Reimbursement

Policy CodePolicy N/A

Change TypeTemplate updates / minor revisions

Effective DateN/A

Next Review DateN/A

Key ActionDo not submit charges for an initial therapy evaluation on multiple dates of service; if the evaluation spans multiple days, bill as a single unit on the date the evaluation is concluded.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

PT/OT Initial Evaluation Coverage Criteria

Covered when the following billing and state-specific requirements are met:

ALL of the following

Providers must use appropriate CPT/state codes for PT and OT initial evaluations as defined by CMS and local state DMS agencies.
Do not submit charges for an initial therapy evaluation for each therapy discipline on multiple dates of service; if the evaluation spans multiple days, bill as a single unit for the entire evaluation service, typically on the day the evaluation is concluded.
Additional minutes required to finalize the evaluation during subsequent sessions as part of therapy are not considered treatment time and should not be billed as separate evaluation units.

State exceptions

CA: Medi‑Cal — therapy evaluation codes are considered excluded (included in the non‑benefit listing).
NY: NY Medicaid — evaluations are excluded (not on the fee schedule).
TX: Texas Medicaid — PT and OT evaluation procedure codes are payable once every three years to the same rendering provider.

Failure to follow the coding and billing guidelines may result in claim denial or recovery of payment by Molina Healthcare.

Codes and State Coding Exceptions

PT/OT evaluation codes (referenced)mixed

PT and OT initial evaluation codes per CMS and local state DMS agencies (not explicitly listed in this document).

Texas frequency limit — PT/OT evaluation codes

Texas frequency limitPT and OT evaluation procedure codes payable once every three years to the same rendering provider (TX Medicaid exception).

ScopeApplies to PT and OT initial evaluation procedure codes when billed to TX Medicaid as noted in state exceptions.

Provider implicationProviders should not bill more frequently than once every three years to the same rendering provider for the listed evaluation codes when TX Medicaid rules apply.

Billing Rules and Provider Responsibilities

Billing Rule

Billing guideline for multi-day evaluations

Do not submit charges for an initial therapy evaluation for each therapy discipline on multiple dates of service. If an evaluation spans multiple days, bill it as a single unit for the entire evaluation service — typically on the date the evaluation is concluded. Additional minutes spent finalizing the evaluation during subsequent sessions that are part of ongoing therapy are not considered separate treatment time and should not be billed as a new initial evaluation.

Multi-day evaluations must be billed as one unit, not as multiple initial evaluations on separate dates.
Bill the evaluation on the date it is completed.
Do not bill additional minutes in later therapy sessions as a separate initial evaluation.

Denial Risk

Coding and claim risk

Use appropriate billing codes as defined by CMS and your local state DMS agencies and follow industry-standard coding practices for all submissions. Failure to adhere to correct coding and billing guidelines may result in claim denial or recovery of payments by Molina Healthcare. Molina reserves the right to revise policies and to reject/deny claims or recover payments when improper billing or coding is identified.

Use CPT codes and code sets required by CMS and state DMS agencies.
Ensure codes are effective on the date of service and not deleted.
Listing of a code in policy does not guarantee coverage — verify against member benefit documents.
Molina may reject/deny claims and recover payments for improper billing; policy may be revised as needed.

OpenPayer

Physical and Occupational Therapy Initial Evaluation Reimbursement

PT/OT Initial Evaluation Coverage

Codes and State Coding Exceptions

Billing Rules and Provider Responsibilities

Acronyms and Terms