CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Physical and Occupational Therapy — Coverage Criteria

Defines coverage, prerequisites, coding, limits, and billing rules for outpatient physical therapy (PT) and occupational therapy (OT) for Neighborhood Health Plan of Rhode Island members across Medicaid (excluding EFP), INTEGRITY, and Commercial lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Physical and Occupational Therapy — Coverage Criteria

Policy CodePolicy N/A

Change TypeRevised & Added (material)

Effective DateN/A

Next Review DateN/A

Key ActionEnsure an order for outpatient therapy from a PCP or treating qualified provider is documented in the medical record and Box 17 of the claim before billing.

SourceLink

POLICY UPDATE CHANGES

INTEGRITY outpatient PT and OT limited to 24 sessions per calendar year with no prior authorization required.

Requirement that members must have an order for outpatient therapy services from a PCP or treating qualified provider separate from the provider rendering therapy services.

24PT session limit per calendar year (INTEGRITY)

24OT session limit per calendar year (INTEGRITY)

1 hrTypical PT session

1 hr

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Coverage criteria and exclusions

Medical Necessity and Administrative Prerequisites

Covered when ALL of the following are met

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

Provider must verify eligibility, coverage, and authorization criteria prior to rendering services.

Services that are considered general conditioning programs are not covered. Examples include activities provided primarily to improve overall fitness, endurance, or conditioning without a specific, documented therapeutic goal tied to a medical diagnosis or functional deficit. Also excluded are programs directed at vocational training, job adaptability, or job placement, and rehabilitative services intended solely to restore function for a member's specific occupation. In addition, services provided solely for the convenience of the member or the provider are not reimbursable.

All services must be medically necessary to qualify for reimbursement. Neighborhood may use National Coverage Determinations (NCD), Local Coverage Determinations (LCD), industry-accepted criteria such as InterQual, EOHHS recommendations, and Clinical Medical Policies (CMP) to determine medical necessity. Explicit non-covered services include general conditioning programs, vocational rehabilitation, testing and screening focused on job adaptability or placement, rehabilitative services to restore function for a member's specific occupation, and services provided solely for the convenience of the member or service provider. Providers are responsible for verifying eligibility, coverage, and authorization criteria prior to rendering services.

CPT/HCPCS codes, modifiers, and session limits

PT & OT Evaluation and Re-Evaluation CodesCPT

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 CodesCPT | HCPCS | Other

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 billing modifiersModifier

GO	Modifier - Services delivered under an outpatient OT plan of care
GP	Modifier - Services delivered under an outpatient PT plan of care
CO	Modifier - Occupational therapy services furnished in whole or in part by an OTA
CQ	Modifier - Outpatient physical therapy services furnished in whole or in part by a PTA

inv-07: Session limits

Session limit (PT)24 sessions per calendar year for outpatient physical therapy (INTEGRITY line of business)

Session limit (OT)24 sessions per calendar year for outpatient occupational therapy (INTEGRITY line of business)

Prior authorizationNo prior authorization is required for outpatient PT or OT up to the 24-session calendar year limit (INTEGRITY).

Provider responsibilities, documentation, and billing rules

Prior Authorization

INTEGRITY session limits / prior auth

Outpatient Physical Therapy is limited to 24 sessions per calendar year. No prior authorization is required for these INTEGRITY limits.

Limit applies per calendar year
No prior authorization required for up to 24 sessions for PT

Documentation Required

Order and plan of care documentation

Members must receive an order for outpatient therapy services from their primary care provider (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 services must relate to a written treatment plan established prior to treatment by a physician, NPP, PT, or OT.

Order must be from a PCP or treating qualified provider separate from the therapy provider

Background and rationale

Physical therapy (PT) and occupational therapy (OT) are rehabilitative disciplines with distinct but complementary aims. PT focuses on improving movement, strength, endurance, balance, coordination, joint mobility, flexibility, posture, gait and pain management through therapeutic exercise and other interventions. OT emphasizes task-based, goal-directed activities to restore or improve functional performance in activities of daily living and to address neuromusculoskeletal and psychosocial dysfunction. Both therapies are intended to restore function, facilitate recovery from acute illness or injury, and support meaningful, documented functional goals within a written plan of care.

Key definitions

inv-13: Physical therapy (PT) definition

DefinitionPhysical therapy (PT): treatment using therapeutic exercise and other interventions to improve posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, activities of daily living, and to alleviate pain.

Typical sessionA PT session is typically defined as up to 1 hour of treatment and/or evaluation, or up to 3 PT modalities on any given day.

PurposeFocused on restoring or improving functional movement and reducing impairment from disease or injury.

inv-14: Occupational therapy (OT) definition

DefinitionOccupational therapy (OT): rehabilitation therapy using specific tasks or goal-directed activities to improve functional performance for neuromusculoskeletal and psychological dysfunction.

Typical session