CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Physical Therapy (PT) and Occupational Therapy (OT) Coverage Criteria

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

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Physical Therapy (PT) and Occupational Therapy (OT) Coverage Criteria

Policy CodePolicy N/A

Change TypeAuthorization and modifier updates

Effective Date

Next Review Date

Key ActionObtain prior authorization for all PT and OT services before rendering care per line of business deadlines.

SourceLink

POLICY UPDATE CHANGES

Updated authorization language for INTEGRITY effective March 1, 2025, requiring authorizations for all PT and OT services as of March 31, 2025.

Updated authorization language for Medicaid and Commercial effective June 1, 2024, requiring authorization for all PT and OT services as of June 15, 2024.

Added CO/CQ modifier reimbursement language effective July 15, 2024.

3Lines of business explicitly in scope

Jun 15, 2024Auth required date for Medicaid & Commercial

Mar 31, 2025Auth required date for INTEGRITY

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.

Typical PT/OT session duration

MultipleCode listings included

Coverage and Medical Necessity

General medical necessity and prerequisite criteria

Covered when ALL of the following are met

Prerequisites: Member has a separate order for outpatient therapy from a PCP or treating qualified provider documented in the medical record and noted in Box 17 on the claim; services relate directly to a written treatment plan (plan of care) 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, and are intended to restore function or treat an acute illness/injury or acute exacerbation with significant potential for functional recovery; services are performed by a contracted Physical or Occupational Therapist or a contracted therapy group to be reimbursed.

The following services are expressly excluded from coverage: general conditioning programs (programs intended primarily to improve overall fitness or well‑being rather than to treat a specific injury or disease); vocational rehabilitation, testing, and screening that focus on job adaptability or job placement; rehabilitative services intended to restore function for a member’s specific occupation (occupation‑specific restorative services); and services provided solely for the convenience of the member or the service provider.

These exclusions mean claims for therapy that are primarily evaluative for employment purposes, aimed at workplace re‑entry without a documented medical need, or that provide only general fitness benefits are not considered medically necessary and will not be covered. Providers should ensure therapy plans clearly document the medical diagnosis, functional deficits, and restorative goals tied to treating an acute illness, injury, or exacerbation with expected functional recovery to support coverage.

CPT, HCPCS, Modifiers, and Session Rules

PT & OT Evaluation and Re-Evaluation Codes (partial list)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

PT & OT Modalities and Therapeutic Procedure Codesmixed

97167	Occupational therapy evaluation, high complexity
97168	Re-evaluation of occupational therapy established plan of care
97010	Hot or cold packs
97012	Traction, mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Diathermy
97026	Infrared

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Required modifiersModifierCovered

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: Typical session duration — Up to 1 hour per PT or OT session

Typical session durationUp to 1 hour per physical therapy (PT) or occupational therapy (OT) session

PT session detailIncludes treatment and/or evaluation within the 1-hour session

OT session detailOccupational therapy sessions are also typically up to 1 hour for treatment and/or evaluation

inv-08: Modalities per PT day — Up to 3 PT modalities per day

Modalities per PT dayUp to 3 PT modalities provided on any given day

Modality counting

Authorization, Documentation, and Billing Requirements

Note

Medical necessity determination sources

Authorizations are required, documentation must support medical necessity and referring orders, and correct billing modifiers must be used. Neighborhood may use NCDs, LCDs, InterQual, EOHHS recommendations, and its Clinical Medical Policies to determine medical necessity. Providers must verify eligibility, coverage, and authorization criteria prior to rendering services.

Authorization required for all PT and OT services (Commercial & Medicaid effective June 15, 2024; INTEGRITY effective March 31, 2025).
All services must be medically necessary and supported by documentation in the medical record.
Providers are responsible for verifying eligibility, coverage, and authorization requirements before rendering services.

Denial Risk

Missing referring provider/order

Members must have a separate order from their PCP or treating qualified provider documented in the medical record and on the claim (Box 17 referring provider). Services may be denied if no separate order/referral is present.

Clinical Background

Physical therapy is focused on the use of therapeutic exercise and other interventions to address impairments in mobility, strength, balance, joint mobility, and pain that limit function. Common PT interventions include therapeutic exercise (strengthening, range‑of‑motion, balance and gait training), manual therapy techniques, modality use (eg, heat/cold, ultrasound, electrical stimulation), and functional retraining to restore or improve activities of daily living and mobility. Occupational therapy complements PT by using task‑ and goal‑directed activities to improve functional performance related to self‑care, work, and community participation.

Key Definitions

inv-16: Physical therapy (PT) — definition/short description

DefinitionPhysical therapy (PT) is the treatment of disease or injury by therapeutic exercise and other interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, functional activities of daily living, and alleviating pain.

GoalsRestore or improve mobility, strength, balance, joint mobility, flexibility, and ability to perform activities of daily living

InterventionsTherapeutic exercise and other interventions tailored to functional recovery

inv-17: Occupational therapy (OT) — definition/short description

DefinitionOccupational therapy (OT) is a form of rehabilitation therapy involving treatment of neuromusculoskeletal and psychological dysfunction through the use of specific tasks or goal-directed activities designed to improve an individual’s functional performance.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Physical Therapy (PT) and Occupational Therapy (OT) Coverage Criteria

Policy CodePolicy N/A

Change TypeAuthorization and modifier updates

Effective Date

Next Review Date

Key ActionObtain prior authorization for all PT and OT services before rendering care per line of business deadlines.

SourceLink

On This Page

Modalities counted toward the daily limit regardless of combination within the same visit

OT modalitiesOccupational therapy modality limit is not specified beyond the 1-hour session definition

Ordering/referring provider must be documented in the member's medical record and noted in Box 17 on the claim.
Order/referral must be separate from the provider rendering therapy services.

Documentation Required

Written plan of care and referral documentation

A written treatment plan (plan of care) must be established prior to treatment by a physician, NPP, PT, or OT. Therapy services must relate directly to that plan and be consistent with condition, safety, and functional recovery goals.

Treatment plan must be in the medical record before services begin.
Plan of care must justify the nature, frequency, and duration of services.
Services must be provided by a contracted PT/OT or contracted therapy group to be reimbursed.

Documentation Required

PTA/OTA supervision and modifier documentation

When services are provided by a PTA or OTA, documentation must support the required supervision and the appropriate assistant modifier (CQ for PTA, CO for OTA) must be appended. Supervising therapists must be accessible by telecommunications, provide regular documented conferences, and conduct required on-site supervisory visits (including reexamination, plan-of-care review/modification, and discharge planning) at least monthly or more frequently as patient needs dictate.

PT/OT must be available by telecommunications while PTA/OTA is treating patients.
Document regularly scheduled conferences between supervising therapist and PTA/OTA.
Supervisory on-site visits required: on request for reexamination, prior to discharge, when plan of care changes, at least once monthly (or more often as needed).
Use modifier CO for services furnished in whole or in part by an OTA; use modifier CQ for services furnished in whole or in part by a PTA.

Billing Rule

Missing discipline modifier

Certain CPT/HCPCS codes must be billed with a discipline modifier to indicate whether the service was delivered under an OT or PT plan of care. Claims will deny if the required discipline modifier is not appended.

Append GO for services delivered under an outpatient OT plan of care.
Append GP for services delivered under an outpatient PT plan of care.
If services by an OTA/PTA include assistant participation, also append CO (OTA) or CQ (PTA) as applicable.
Neighborhood applies CMS reimbursement rules for assistant modifiers across all lines of business.

Improve functional performance for activities of daily living through task- and goal-directed activities

ScopeAddresses neuromusculoskeletal and psychological dysfunction using targeted therapeutic activities