CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

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

Defines coverage, authorization, and billing requirements 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.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

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

Policy CodePolicy N/A

Change TypeAuthorization & coding updates

Effective DateJun 1, 2024

Next Review Date

Key ActionObtain prior authorization for PT/OT when visits exceed 24 per discipline per calendar year for INTEGRITY and follow Evolent Health authorization requirements for Commercial and Medicaid starting June 15, 2024.

SourceLink

POLICY UPDATE CHANGES

Updated authorization language for Medicaid and Commercial.

Added CO/CQ modifier reimbursement language effective 7/15/24.

Updated visit limits and authorization requirement language for INTEGRITY.

24visits without prior auth (INTEGRITY / year)

Jun 15, 2024Evolent management effective

GO/GP/CO/CQrequired claim modifiers

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Coverage and Exclusions

Medical necessity and basic coverage

Covered when ALL of the following are met

General coverage criteria: 1) Member has a valid order for outpatient therapy from a PCP or treating qualified provider separate from the provider rendering therapy; the ordering/referring provider is documented in the member's medical record and noted in Box 17 on the claim. 2) Services 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. 3) Services are consistent with the nature and severity of the illness, are safe and effective for the patient’s condition, and are intended to restore function or are part of treatment for an acute illness/injury or acute exacerbation with significant potential for functional recovery. 4) Services are performed by a contracted Physical or Occupational Therapist or a contracted therapy group. 5) Session length: PT or OT sessions are typically up to 1 hour per session (or up to 3 PT modalities per day).

Providers must verify eligibility, coverage, and authorization prior to services.

Coverage for outpatient physical and occupational therapy is provided when services meet the policy's medical necessity requirements and are directly related to a written treatment plan established prior to treatment. Services should be consistent with the nature and severity of the member's condition, be safe and effective, and aim to restore function or treat an acute illness, injury, or exacerbation with significant potential for functional recovery. A typical PT or OT session is up to 1 hour (or up to three PT modalities per day). Providers must verify member eligibility, coverage, and any authorization requirements before initiating services.

The following services are explicitly excluded from coverage: general conditioning programs; vocational rehabilitation, testing and screening focused on job adaptability or job placement; rehabilitative services intended to restore function for a member's specific occupation; and services provided solely for the convenience of the member or service provider.

Code Sets, Modifiers, and Visit 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 | 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

1–10 of 33

1/4

Required ModifiersModifier

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

INTEGRITY visit limit without prior authorization

Limit24 visits per discipline per calendar year (no prior authorization required)

When prior authorization is requiredPrior authorization required for any visits over 24 per discipline in a calendar year

Applies toOutpatient Physical Therapy and Outpatient Occupational Therapy under INTEGRITY

Authorization, Documentation, and Billing Requirements

Denial Risk

Missing discipline modifier causes denial

No discipline modifier appended to claim lines for the codes in Table 2 will cause the claim to deny. Append the appropriate modifier to indicate the discipline delivering the service.

Required discipline modifiers: GO (OT plan of care), GP (PT plan of care)
Required assistant modifiers when applicable: CO (OTA), CQ (PTA)
If a required modifier is missing, claim lines will deny

Documentation Required

Order and plan of care documentation

Members must have an order from the PCP or treating qualified provider separate from the therapy provider. The ordering/referring provider must be documented in the member's medical record and noted in Box 17 (referring provider) on the claim. Outpatient rehabilitation services must relate directly to a written treatment plan (plan of care) established prior to treatment by a physician, NPP, physical therapist, or occupational therapist. The plan of care must be available in the medical record and include the clinical rationale and treatment goals.

Background

Physical therapy is the treatment of disease or injury through therapeutic exercise and interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, functional activities of daily living, and pain alleviation. Occupational therapy uses task- and goal-directed activities to improve functional performance for neuromusculoskeletal and psychological dysfunction. Both disciplines are intended to restore or improve function related to the member's clinical condition rather than provide general conditioning or vocation-specific training.

Key Definitions

Physical therapy (PT) — definition and scope

DefinitionTreatment of disease or injury using therapeutic exercise and other interventions focused on posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, functional activities of daily living, and pain alleviation.

Typical session lengthTypically up to 1 hour of PT per session (or up to 3 PT modalities per day).

Primary goalsImprove mobility, strength, endurance, balance, coordination, joint mobility, and functional performance; alleviate pain.

Occupational therapy (OT) — definition and scope

DefinitionRehabilitation therapy using specific tasks or goal-directed activities to improve functional performance for individuals with neuromusculoskeletal and psychological dysfunction.

Primary focus