ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Physical and Occupational Rehabilitation Services Payment Policy – Archive 9

Defines payer requirements for outpatient physical therapy (PT) and occupational therapy (OT) services across Medicaid (excluding EFP), INTEGRITY, and Commercial lines, including prerequisites, medical necessity references, visit authorization thresholds, modifier and assistant billing rules, covered CPT/HCPCS codes (evaluation, modalities, procedures), exclusions, and claims submission requirements.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysical and Occupational Rehabilitation Services Payment Policy – Archive 9

Policy CodePolicy N/A

Change TypeRevised (multiple dates); Clarified

Effective Date

Next Review Date

Key ActionINTEGRITY: prior authorization required for PT/OT visits exceeding 24 visits per discipline per calendar year; Commercial and Medicaid: authorization required for all PT/OT services effective 2024-06-15.

SourceLink

POLICY UPDATE CHANGES

Updated authorization language for Medicaid and Commercial effective 06/01/2024 and partnership with Evolent Health to require authorization for all PT/OT services effective 06/15/2024.

10/01/2023 updated visit limits and authorization requirement language for Integrity.

03/29/2023 annual review with no content changes.

01/01/2023 update to INTEGRITY to remove language around auth requirement after 24 visits.

04/01/2021 removed limit of 24 visits for Medicaid and Commercial LOBs effective 04/01/2021.

02/01/2022 added requirement for referring provider documentation.

24INTEGRITY visits without auth (per discipline/yr)

2024-06-15Auth required for Commercial & Medicaid

Assistant modifiers required

Policy Summary & Scope

This policy is from Neighborhood Health Plan and applies to outpatient Physical Therapy (PT) and Occupational Therapy (OT) across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business. It defines prerequisites and medical necessity for reimbursable outpatient PT/OT services, billing requirements (including required discipline modifiers and assistant modifiers), visit authorization thresholds by line of business, and exclusions. The policy references external coding and clinical standards including CPT, ICD-10-CM, and HCPCS, and permits Neighborhood to use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), InterQual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity. It also allows payer edits, prior authorization, and audit/review of billed services.

Key Thresholds & Dates

INTEGRITY visit allowance24 visits per discipline per calendar year without authorization

Authorization effective date for Commercial and Medicaid under Evolent managementAll PT/OT services require authorization as of 2024-06-15

CO/CQ modifier reimbursement effective dateEffective 2024-07-15

Medical Necessity & Coverage Criteria

Prerequisites / Medical Necessity

Services are reimbursed when ALL of the following are met:

ALL of the following

Member has an order for outpatient therapy services from their PCP or treating qualified provider that is separate from the provider rendering therapy services; the ordering/referring provider must be documented in the member's medical record and noted in Box 17 on the claim.
Outpatient rehabilitation therapy services must relate directly and specifically to a written treatment plan (plan of care) established prior to treatment by a physician, NPP, physical therapist, or occupational therapist.
Services must be consistent with nature and severity of illness, considered safe and effective for the patient's condition, used to restore function or as part of defined treatment for acute illness/injury or acute exacerbation of chronic illness with significant potential for functional recovery.
Services must be performed by a contracted Physical or Occupational Therapist or contracted Therapy group to be reimbursed.

Code Lists & Modifiers

PT & OT Evaluation and Re-evaluation Codes (may be applicable)CPT

97161	Physical therapy evaluation: low complexity (typically 20 minutes)
97162	Physical therapy evaluation: moderate complexity (typically 30 minutes)
97163	Physical therapy evaluation: high complexity (typically 45 minutes)
97164	Re-evaluation of physical therapy established plan of care (typically 20 minutes)
97165	Occupational therapy evaluation, low complexity (typically 30 minutes)
97166	Occupational therapy evaluation, moderate complexity (typically 45 minutes)
97167	Occupational therapy evaluation, high complexity (typically 60 minutes)
97168	Re-evaluation of occupational therapy established plan of care (typically 30 minutes)

PT & OT Modalities and Therapeutic Procedure Codes (may be applicable)mixed

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

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Required Discipline ModifiersModifier

GO	Services delivered under an outpatient OT plan of care (required or claim will deny)
GP	Services delivered under an outpatient PT plan of care (required or claim will deny)
CO	Occupational therapy services furnished in whole or in part by an OTA (required when applicable)
CQ	Outpatient physical therapy services furnished in whole or in part by a PTA (required when applicable)

Billing, Documentation & Authorization Actions

Prior Authorization

Authorization for visits beyond thresholds or per LOB

INTEGRITY: prior authorization is required for PT/OT visits exceeding 24 visits per discipline per calendar year. Commercial and Medicaid: authorization is required for all PT/OT services effective 2024-06-15.

INTEGRITY: 24-visit rule (no auth for first 24 visits per discipline; prior auth required thereafter)
Commercial/Medicaid: authorization required for all PT/OT services as of 2024-06-15

Documentation Required

Order and Referring Provider Documentation

Obtain and document an order for outpatient therapy from the member's PCP or treating qualified provider that is separate from the therapy provider. The ordering/referring provider must be documented in the member's medical record and noted in Box 17 on the claim.

Key Definitions

Definitions

Physical therapy sessionTypically up to 1 hour of PT (treatment and/or evaluation) or up to 3 PT modalities provided on any given day.

Occupational therapy sessionTypically up to 1 hour of occupational therapy (treatment and/or evaluation) on any given day.

Policy Revision Timeline

2024-06-01annual_reviewLatest

Annual review: Updated authorization language for Medicaid and Commercial.

2024-06-15authorization_changeLatest

Neighborhood partnered with Evolent Health; authorization required for all physical and occupational therapy services for Commercial and Medicaid effective June 15, 2024.

2024-07-15billing_rule_change

Frequently Asked Questions

Q: Where do providers get authorization details? A: Authorization rules differ by line of business: for INTEGRITY no prior authorization is required for the first 24 visits per discipline per calendar year; prior authorization is required for visits beyond 24. For Commercial and Medicaid, Neighborhood is partnering with Evolent Health and authorization will be required for all PT/OT services as of 2024-06-15. Contact Evolent/INTEGRITY or Neighborhood Provider Services for line-of-business specific prior authorization instructions.

Q: What claim documentation is required? A: Obtain and document an order for outpatient therapy from the member's PCP or treating qualified provider (must be separate from the therapy provider). Document the ordering/referring provider in the member's medical record and enter the referring provider in Box 17 on the claim as required.

Q: What modifiers are required on claims? A: Append GO (OT) or GP (PT) to the listed therapy codes to indicate discipline (claims will deny if missing). When services are furnished in whole or in part by assistants append CO for OTA and CQ for PTA; Neighborhood will apply CMS reimbursement rules to these modifiers (CO/CQ reimbursement language effective 2024-07-15).

Q: Other billing reminders: A: Billable services remain subject to contractual agreements and timely filing requirements; coding must meet CPT, ICD-10-CM, and HCPCS standards; and providers should confirm eligibility, coverage, and authorization prior to rendering services.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysical and Occupational Rehabilitation Services Payment Policy – Archive 9

Policy CodePolicy N/A

Change TypeRevised (multiple dates); Clarified

Effective Date

Next Review Date

SourceLink

On This Page

All services must be medically necessary; Neighborhood may use NCD, LCD, InterQual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.

PTA / OTA Supervision Requirements

When services are performed by PTAs/OTAs in general supervision/off-site settings, ALL of the following must be observed:

ALL of the following

Physical therapist must be accessible by telecommunications to the PTA at all times while PTA is treating patients/clients.
There must be regularly scheduled and documented conferences with the PTA regarding patients; frequency determined by needs of patient and PTA.
Supervisory visit by the physical therapist is required upon PTA's request for reexamination, when a change in plan of care is needed, prior to planned discharge, in response to change in patient's medical status, and at least once a month (or more frequently as determined).
A supervisory visit must include on-site reexamination, on-site review and revision/termination of plan of care, and evaluation of need/recommendation for outside resources.

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Visit Authorization Rules by Line of Business

Authorization required rules as specified by line of business:

ANY of the following

INTEGRITY
- Outpatient Physical Therapy - No authorization needed for the first 24 visits per calendar year; prior authorization required for anything over 24 visits. (24 visits per discipline)24 visits per discipline per calendar year
- Outpatient Occupational Therapy - No authorization needed for the first 24 visits per calendar year; prior authorization required for anything over 24 visits. (24 visits per discipline)24 visits per discipline per calendar year
Commercial and Medicaid
- Effective June 1, 2024 Neighborhood is partnering with Evolent Health to manage physical medicine services; authorization will be required for all physical and occupational therapy services as of June 15, 2024.Authorization required effective 2024-06-15

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Coverage Exclusions

The following services are NOT covered:

ANY of the following

General Conditioning Programs
Vocational rehabilitation, testing and screening focusing on job adaptability, job placement
Rehabilitative services to restore function for a member's specific occupation
Services provided solely for the convenience of the member or service provider

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Billing Rule

Discipline and Assistant Modifiers Required

Discipline modifiers GO (OT) and GP (PT) are required on the listed therapy codes; claims will deny if these modifiers are not appended. When services are provided in whole or in part by assistants, CO is required for OTA services and CQ is required for PTA services. Neighborhood will apply CMS reimbursement rules to these assistant modifiers; CO/CQ reimbursement language is effective 2024-07-15.

GO/GP required — claim will deny if missing
CO/CQ required when OTA/PTA provide services; CMS reimbursement rules apply
CO/CQ effective date: 2024-07-15

Documentation Required

Treatment Plan / Plan of Care Required

Therapy services must relate directly to a written treatment plan (plan of care) that is established prior to treatment by an authorized clinician (physician, NPP, physical therapist, or occupational therapist). Document and follow the plan of care before providing treatment.

Billing Rule

Provider Contract & Timely Filing

Billable therapy services are subject to provider contractual agreements and must be submitted within contractually determined timely filing guidelines. Coverage and payment are subject to contract terms and claims submission rules.

Denial Risk

Claims Deny if Discipline Modifier Missing

Risk: Claims for therapy services will deny if the required GO or GP discipline modifier is not appended to the therapy codes.

Added CO/CQ modifier reimbursement language (assistant modifiers) effective July 15, 2024; Neighborhood will apply CMS reimbursement rules to these modifiers.

2023-10-01authorization_update

Updated visit limits and authorization requirement language for INTEGRITY.

2023-03-29annual_review

Annual review conducted with no content changes.

2023-01-01authorization_change

INTEGRITY update effective January 1, 2023: removed language that had required authorization after 24 visits.

2022-02-01documentation_requirement

Added requirement to document the referring/provider order for outpatient therapy and note the referring provider in the member's medical record and Box 17 on the claim.

2021-04-01visit_limit_removal

Removed limit of 24 visits for Medicaid and Commercial lines of business effective April 1, 2021.