CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Physical And Occupational Rehabilitation Services 02.01.22 Eff 4.01.22

Defines prerequisites, medical necessity, coverage limits, billing modifiers, covered CPT/HCPCS codes for outpatient physical and occupational therapy across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business for Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysical And Occupational Rehabilitation Services 02.01.22 Eff 4.01.22

Policy CodePolicy N/A

Change TypeRequirement added for referring provider documentation

Effective Date4/01/22

Next Review Date

Key ActionObtain and document an order for outpatient therapy from a PCP or treating qualified provider separate from the therapy provider; record ordering/referring provider in medical record and Box 17 on claim.

SourceLink

POLICY UPDATE CHANGES

Requirement for referring provider to be documented and noted in Box 17 on the claim.

Removed prior limit of 24 visits for Medicaid and Commercial LOBs effective 4/1/21 (historical change).

Commercial and INTEGRITY benefit limits/authorization requirements updated effective 1/1/21.

24PT sessions w/o prior auth (per calendar year)

24OT sessions w/o prior auth (per calendar year)

1 hourTypical session length

3Max PT modalities per day

Policy Overview

Payer: Neighborhood Health Plan of Rhode Island. Policy title: Outpatient Physical and Occupational Therapy (PT/OT) services billing and coverage rules. Target lines of business: Medicaid (excluding EFP), INTEGRITY, and Commercial.

High-level scope: This policy defines Physical Therapy (PT) and Occupational Therapy (OT), their therapeutic goals and services, and the expectation that services are medically necessary and must relate directly and specifically to a written treatment plan (plan of care) established prior to treatment. PT is described as treatment using therapeutic exercise and other interventions to improve function, mobility, strength, endurance, balance, coordination, joint mobility, flexibility, and to alleviate pain. OT is described as rehabilitation using specific tasks or goal-directed activities to improve functional performance for neuromusculoskeletal and psychological dysfunction.

Key administrative and billing scope points: Members must have an order for outpatient therapy from their PCP or treating qualified provider separate from the therapy provider, and the ordering/referring provider must be documented in the medical record and noted in Box 17 on the claim. Services must be performed by a contracted PT/OT or contracted therapy group. Session definitions limit PT/OT to up to 1 hour per day (PT may include up to 3 PT modalities on a given day). Required discipline modifiers include GO (OT), GP (PT), CO (OTA involvement), and CQ (PTA involvement).

Medical necessity determinations and reliance: All services must be medically necessary to qualify for reimbursement. Neighborhood may use National Coverage Determination (NCD), Local Coverage Determination (LCD), industry-accepted criteria such as InterQual, EOHHS recommendations, and Clinical Medical Policies (CMP) to determine medical necessity.

Policy history note: The document records updates including the 02/01/22 update (effective 4/1/22) adding the requirement to document the referring provider in Box 17, prior changes effective 4/1/21 and 01/01/21 to benefit limits and prior authorization structures.

Header Facts

PayerNeighborhood Health Plan of Rhode Island

Policy TitleOutpatient Physical and Occupational Therapy (PT/OT) services billing and coverage rules

Policy NumberN/A

Effective Date4/1/22 (requirement for referring provider)

Last Review2022-02-01

Next Review

Scope SummaryDefines prerequisites, medical necessity, coverage limits, billing modifiers, and covered CPT/HCPCS codes for outpatient PT and OT across Medicaid (excl. EFP), INTEGRITY, and Commercial lines of business for Neighborhood HPRI.

Coverage Criteria & Limits

Prerequisites for Reimbursement

Services must meet ALL of the following to be reimbursed:

ALL of the following

Order for services: Member must have an order for outpatient therapy services from their PCP or treating qualified provider separate from the provider rendering therapy services.
Ordering/referring provider must be documented in medical record and noted in Box 17 on claim.
Written plan of care: Outpatient rehabilitation therapy services must relate directly and specifically to a written treatment plan (plan of care) established prior to treatment by a physician, an NPP, a physical therapist, or an occupational therapist.
Treatment plan must be established by a physician, an NPP, a physical therapist, or an occupational therapist.
Medical necessity:

Code Lists

PT & OT Evaluation and Re-evaluation Codes (listed as applicable)CPT

97161	Physical therapy evaluation: low complexity
97162	Physical therapy evaluation: moderate complexity
97163	Physical therapy evaluation: high complexity
97164	Re-evaluation of physical therapy established plan of care
97165	Occupational therapy evaluation, low complexity
97166	Occupational therapy evaluation, moderate complexity
97167	Occupational therapy evaluation, high complexity
97168	Re-evaluation of occupational therapy established plan of care

PT & OT Modalities and Therapeutic Procedure Codes (listed as applicable)mixed

97010	Hot or cold packs
97012	Traction, mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy (eg, microwave)
97026	Infrared
97028	Ultraviolet
97032	Electrical stimulation (manual), each 15 minutes

1–10 of 35

1/4

Required Discipline ModifiersModifier

GO	Services delivered under an outpatient OT plan of care
GP	Services delivered under an outpatient PT plan of care
CO	OT services furnished in whole or in part by an OTA (required when OTA provides service)
CQ	Outpatient PT services furnished in whole or in part by a PTA (required when PTA provides service)

Provider Requirements & Billing Rules

Documentation Required

Order and Referring Provider Documentation

Obtain and document an order from the referring/provider distinct from the therapy service provider before rendering outpatient PT/OT services. The ordering/referring provider must be recorded in the member's medical record and Box 17 (referring provider) on the claim.

Document the referring provider and include Box 17 on the claim

Prior Authorization

Prior Authorization Required for >24 Sessions

For INTEGRITY and Commercial lines of business, more than 24 outpatient PT sessions or more than 24 outpatient OT sessions per calendar year require prior authorization BEFORE services are rendered.

Limit without prior authorization: 24 PT sessions/calendar year; 24 OT sessions/calendar year

Key Definitions

Definitions

Physical Therapy (PT)Treatment using therapeutic exercise and other interventions to improve posture, mobility, strength, endurance, balance, coordination, joint mobility, flexibility, activities of daily living, and to alleviate pain.

Occupational Therapy (OT)Rehabilitation therapy using specific tasks or goal-directed activities to improve functional performance for neuromusculoskeletal and psychological dysfunction.

Policy Revision Timeline

02/01/22addedLatest

Requirement added to document the ordering/referring provider in the member's medical record and to note the referring provider in Box 17 on the claim; effective 04/01/22.

04/01/21revised

Removed prior limit of 24 visits for Medicaid and Commercial lines of business (historical change); policy currently retains a 24-session without prior authorization limit for INTEGRITY and Commercial.

01/01/21revised

Updated benefit limit structure and Medicaid year basis (Commercial and INTEGRITY benefit limits/authorization requirements updated; Medicaid limit changed from rolling year to calendar year).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysical And Occupational Rehabilitation Services 02.01.22 Eff 4.01.22

Policy CodePolicy N/A

Change TypeRequirement added for referring provider documentation

Effective Date4/01/22

Next Review Date

SourceLink

On This Page

Services must be consistent with the nature and severity of illness, considered safe and effective, used to restore function, or provided as part of a defined treatment plan for an acute illness/injury or acute exacerbation with significant potential for functional recovery.

Neighborhood may use NCD/LCD, InterQual, EOHHS recommendations, Clinical Medical Policies (CMP) to determine medical necessity.

Contracted provider requirement: Services must be performed by a contracted Physical or Occupational Therapist or a contracted Therapy group to be reimbursed.

PTA/OTA supervision: When a PTA/OTA provides services under general supervision, the supervising PT must be accessible by telecommunications at all times; there must be regularly scheduled and documented conferences; and supervisory on-site visits must occur at least once a month or more frequently as needed and upon triggers (request for reexamination, change in plan of care, prior to planned discharge, change in medical status).

Supervisory visit must include on-site reexamination, on-site review of plan of care, and evaluation of need for outside resources.

Requests for additional sessions must be authorized in advance

Billing Rule

Required Modifiers

Certain modifiers are required on claims to indicate discipline and assistant services. If required modifiers are missing, those claims will deny.

Discipline modifiers: GO = OT plan of care; GP = PT plan of care
Assistant modifiers: CO = services furnished in whole or in part by an OTA; CQ = services furnished in whole or in part by a PTA
Missing required modifiers will result in denial for the affected procedure codes listed in the Coding section

Billing Rule

Session Definition for Daily Billing

A PT session is typically defined as up to 1 hour of PT (treatment and/or evaluation) or up to 3 PT modalities on any given day. An OT session is typically defined as up to 1 hour of occupational therapy (treatment and/or evaluation) on any given day.

Limit: up to 1 hour per PT or OT session per day
PT may include up to 3 modalities per day

Denial Risk

Denial Risk for Non‑contracted Providers

Services provided by non‑contracted therapists or non‑contracted therapy groups are not reimbursable and present a high risk of denial.

Verify the therapist or therapy group is contracted with Neighborhood prior to providing services

Documentation Required

PTA/OTA Supervision & Documentation

When services are furnished by a PTA or OTA under general supervision, the supervising PT/OT must be available by telecommunications and must meet documented supervisory visit requirements.

Supervising PT/OT must be accessible by telecommunications at all times while PTA/OTA is treating patients/clients
Regularly scheduled and documented conferences between PT/OT and PTA/OTA, frequency determined by patient and assistant needs
Supervisory on-site visit required upon PTA/OTA request for reexamination, when a change in plan of care is needed, prior to planned discharge, or in response to a change in the patient's medical status
At minimum, a supervisory visit must occur at least once a month (or more often as clinically indicated) and include on-site reexamination, on-site review and revision/termination of the plan of care, and evaluation of need for outside resources
Document supervisory visits and conferences in the medical record

Denial Risk

Exclusionary Services — Do Not Bill

The following service types are excluded — do not bill Neighborhood for these services as they are not covered under this rehabilitation therapy policy.

General conditioning programs
Vocational rehabilitation, testing, and screening focused on job adaptability or placement
Rehabilitative services intended to restore function for the member's specific occupation
Services provided solely for the convenience of the member or service provider

Documentation Required

Plan of Care Requirement

Treatment must relate directly to a written treatment plan (plan of care) that is established prior to treatment by an authorized clinician and maintained in the patient's record.

Plan of care must be established before treatment and authored by a physician, NPP, PT, or OT
Maintain the written treatment plan in the medical record and ensure services provided are consistent with the plan