CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Physical and Occupational Rehabilitation Services Payment Policy – Archive 10

Defines payment, billing, supervision, coverage exclusions, coding and authorization requirements for outpatient physical therapy (PT) and occupational therapy (OT) across Medicaid (excluding EFP), INTEGRITY, and Commercial lines for Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysical and Occupational Rehabilitation Services Payment Policy – Archive 10

Policy CodePolicy N/A

Change TypeAuthorization & billing updates

Effective Date

Next Review Date

Key ActionEnsure required authorizations are obtained (Commercial/Medicaid effective 06/15/2024; INTEGRITY effective 03/31/2025) and document the ordering/referring provider in the medical record and Box 17 on the claim prior to rendering services.

SourceLink

POLICY UPDATE CHANGES

Updated authorization language for INTEGRITY effective 03/01/2025.

Updated authorization language for Medicaid and Commercial effective 06/01/2024 and auth effective 06/15/2024.

Added requirement for referring provider documentation on 02/01/2022.

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

2LOBs with auth changes

4Required modifiers

~40

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Policy Summary & Scope

This policy defines reimbursement requirements for outpatient physical therapy (PT) and occupational therapy (OT). To qualify for payment, services must be medically necessary, relate directly to a written plan of care established prior to treatment, and be performed by a contracted Physical or Occupational Therapist or contracted therapy group. The ordering/referring provider must be documented in the member's medical record and noted in Box 17 on the claim. Neighborhood may rely on NCDs, LCDs, InterQual, EOHHS, and internal Clinical Medical Policies to determine medical necessity. This policy applies to the Commercial, Medicaid (excluding EFP), and INTEGRITY lines of business, and includes authorization requirements with Evolent Health partnership effective dates reflected in the policy history.

Policy Metadata

PayerNeighborhood Health Plan of Rhode Island

Policy TitlePhysical and Occupational Rehabilitation Services Payment Policy - Archive 10

Policy NumberN/A

StatusCURRENT

Effective Date

Last Review2025-03-01

Next Review

Key ActionsAuthorization updates: Commercial & Medicaid auth required effective 06/15/2024 with Neighborhood partnering with Evolent Health effective 06/01/2024; INTEGRITY auth required effective 03/31/2025 with Evolent partnership effective 03/01/2025. Billing: required discipline modifiers GO (OT) and GP (PT); CO (OTA) and CQ (PTA) required when assistants provide services.

Medical Necessity & Coverage Criteria

Prerequisites / Medical Necessity

Services are reimbursed when ALL of the following are met:

ALL of the following

Member has a written order for outpatient therapy services from the member's primary care provider (PCP) or treating qualified provider that is separate from the provider rendering therapy services and the ordering/referring provider is documented in the member's medical record and noted in Box 17 (referring provider) on the claim.
Outpatient rehabilitation therapy services 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.
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 an acute exacerbation of a chronic illness with significant potential for functional recovery.

Authorization, Documentation & Billing Actions

Prior Authorization

Authorization required (Commercial & Medicaid)

Authorization is required for all physical and occupational therapy services for Commercial and Medicaid. Neighborhood partners with Evolent Health to manage physical medicine services.

Auth required effective June 15, 2024
Evolent partnership effective June 1, 2024

Prior Authorization

Authorization required (INTEGRITY)

Authorization is required for all physical and occupational therapy services for INTEGRITY. Neighborhood partners with Evolent Health to manage physical medicine services.

Auth required effective March 31, 2025
Evolent partnership effective March 1, 2025

Code Lists & Modifier Rules

Evaluation and Re-evaluation CPT Codes (applies to PT & OT)CPTCovered

97161	Physical therapy evaluation: low complexity; typically 20 minutes face-to-face.
97162	Physical therapy evaluation: moderate complexity.
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.

Modalities and Therapeutic Procedure CPT/HCPCS CodesmixedCovered

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 33

1/4

Required Discipline ModifiersModifier

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

Key Terms

Session 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 Changes & Timeline

2025-03-31authorization_updateLatest

Updated authorization language for INTEGRITY; authorizations required for all PT and OT services for INTEGRITY effective March 31, 2025 (Neighborhood partnering with Evolent Health effective March 1, 2025).

2024-07-15billing_rule_changeLatest

Added CO/CQ modifier reimbursement language (required when services provided by OTA/PTA); Neighborhood will apply CMS reimbursement rules to these modifiers, effective July 15, 2024.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPhysical and Occupational Rehabilitation Services Payment Policy – Archive 10

Policy CodePolicy N/A

Change TypeAuthorization & billing updates

Effective Date

Next Review Date

SourceLink

On This Page

Services are performed by a contracted Physical or Occupational Therapist or a contracted Therapy group in order to be reimbursed.

All services are medically necessary. Neighborhood may use criteria such as National Coverage Determination (NCD), Local Coverage Determination (LCD), InterQual, EOHHS recommendations, and Clinical Medical Policies (CMP) to determine medical necessity.

PTA / OTA Supervision Requirements

When PTA/OTA provide services in general supervision, ALL of the following apply:

ALL of the following

A physical therapist must be accessible by telecommunications to the physical therapist assistant or occupational therapist assistant at all times while the assistant is treating patients/clients.
There must be regularly scheduled and documented conferences with the assistant regarding patients/clients, with frequency determined by the needs of the patient/client and the needs of the assistant.
Supervisory visit requirements
- A supervisory visit by the physical therapist will be made upon the assistant's request for a reexamination, when a change in the plan of care is needed, prior to any planned discharge, and in response to a change in the patient's/client's medical status.
- A supervisory visit will be made at least once a month, or at a higher frequency when established by the physical therapist in accordance with the needs of the patient/client.
- A supervisory visit should include an on-site reexamination of the patient/client, on-site review of the plan of care with appropriate revision or termination, and evaluation of need and recommendation for utilization of outside resources.

Coverage Exclusions

The following services are NOT covered:

ALL 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

Session Definitions / Limits

Definitions applied for billing on a given day:

ALL of the following

Physical therapy session: typically defined as up to 1 hour of PT (treatment and/or evaluation) or up to 3 PT modalities provided on any given day.
Occupational therapy session: typically defined as up to 1 hour of occupational therapy (treatment and/or evaluation) on any given day.

Authorization Requirements

Authorization Requirements:

ALL of the following

Providers must verify eligibility, coverage, and authorization criteria prior to rendering services.
Authorization is required for all physical and occupational therapy services for Commercial and Medicaid lines managed by Evolent Health. Effective dates: Commercial and Medicaid: authorizations required as of June 15, 2024; INTEGRITY: authorizations required as of March 31, 2025.
For plan-specific prior authorization procedures, refer to Neighborhood's Prior Authorization Reference page and Neighborhood's Clinical Medical Policies.
Providers are responsible for obtaining any required prior authorization; failure to obtain required authorization may result in denial of claim.

Documentation Required

Ordering/Referring Provider Documentation

Ensure the ordering/referring provider is documented in the member's medical record and noted in Box 17 on the claim prior to rendering services.

Documentation Required

Plan of Care Requirement

Outpatient therapy must relate directly and specifically to a written plan of care established prior to treatment and must be documented in the medical record.

Billing Rule

Session Time Definitions

Define session time limits for billing: a physical therapy session is typically up to 1 hour (treatment and/or evaluation) or may include up to 3 PT modalities on a given day; an occupational therapy session is typically up to 1 hour (treatment and/or evaluation) on a given day.

Up to 1 hour per PT session per day
Up to 1 hour per OT session per day
PT sessions may include up to 3 PT modalities per day

Documentation Required

Provider Contract & Timely Filing

Submit complete claims within contractually determined timely filing guidelines. Billable services are subject to provider contract agreements.

Denial Risk

Exclusionary Services Denied

The following services are excluded from coverage and will be denied: general conditioning programs; vocational rehabilitation, testing and screening focused on job adaptability/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.

General conditioning programs
Vocational rehabilitation/testing and screening
Occupation-specific rehabilitative services
Services provided solely for convenience

Billing Rule

Discipline Modifiers Required

Required discipline modifiers must be appended to listed therapy codes. GO denotes outpatient OT and GP denotes outpatient PT. When services are furnished in whole or in part by assistants, CO is required for OTA and CQ is required for PTA. Failure to append required modifiers will result in denial; Neighborhood will apply CMS reimbursement rules to these modifiers.

Required modifiers: GO (OT) and GP (PT)
Required assistant modifiers: CO (OTA) and CQ (PTA)
Denial if required modifier not appended; CMS reimbursement rules applied

2024-06-01authorization_update

Neighborhood partnered with Evolent Health to manage physical medicine services effective June 1, 2024; authorization required for all PT and OT services for Commercial and Medicaid effective June 15, 2024.

2024-06-01annual_review

Annual review recorded (no material content change noted at this date).

2022-02-01documentation_requirement

Added requirement that the ordering/referring provider must be documented in the member's medical record and noted in Box 17 on the claim.

2021-04-01visit_limit_removal

Removed the 24-visit limit for Medicaid and Commercial lines of business.

2023-03-29annual_review

Annual review recorded with no content changes.