ModifiedNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Physical and Occupational Therapy Services Coverage Criteria

Defines coverage, prerequisites, documentation, coding, and billing requirements for outpatient physical therapy (PT) and occupational therapy (OT) services for Neighborhood Health Plan of Rhode Island members across applicable lines of business.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Physical and Occupational Therapy Services Coverage Criteria

Policy CodePolicy N/A

Change TypeDocumentation and authorization language updatedtemplate/admin updates

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization through Evolent Health for all outpatient PT and OT services before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Updated Documentation Requirements to align with CMS.

Updated authorization language for INTEGRITY and other lines of business on multiple dates.

Updated policy template to include new lines of business and updated Prior Authorizations, Member Responsibility and Disclaimer language.

Authorization requiredAuth managed by Evolent

1 hourSession length

GO/GP & CO/CQRequired modifiers

Table 1 & 2

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Document HistoryRevisions listed

Coverage and Medical Necessity

General medical necessity criteria for outpatient PT/OT

Covered when ALL of the following are met

Order and provider: Member must have an order for outpatient therapy services from their PCP or treating qualified provider separate from the provider rendering therapy; the ordering/referring provider must be documented in the medical record and noted in Box 17 on the claim.

Plan of care: Outpatient rehab services must relate directly to a written treatment plan established prior to treatment by a physician, NPP, PT, or OT and must include diagnoses, short- and long-term goals, therapy type, specific interventions/procedures, amount, duration, and frequency.

Service characteristics: Services must be consistent with illness severity, safe and effective, used to restore function or part of defined treatment for an acute illness/injury or acute exacerbation of chronic illness with potential for functional recovery.

Provider enrollment: Services must be performed by a contracted Physical or Occupational Therapist or contracted Therapy group to be reimbursed.

Authorization is required for all physical and occupational therapy services managed by Evolent Health.

Services for Medicaid children that are defined in the child’s Individualized Education Plan (IEP) must be submitted to Medicaid Fee‑for‑Service rather than to Neighborhood. Also excluded are general conditioning programs, services for vocational rehabilitation, testing and screening for job adaptability or placement, rehabilitative services intended solely to restore function for a member’s specific occupation, and services provided solely for the convenience of the member or provider.

See Document History for prior changes to coverage exclusions. Notably, the policy’s Document History records an update on 03/19/2025 that modified coverage exclusions; additional administrative and template updates are recorded in the 01/01/2026 entry.

General conditioning programs are explicitly excluded from coverage. The policy also excludes services that are primarily vocational in purpose (including testing and job adaptability screening), rehabilitative services intended to restore function only for a member’s specific occupation, and any services provided solely for the convenience of the member or service provider.

Codes, Time Units, and Session Length

PT & OT Evaluation and Modality Codesmixed

97161	Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures
97162	Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements; An evolving clinical presentation; Clinical decision making of moderate complexity; Typically, 30 minutes face-to-face
97163	Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities; An examination addressing 4 or more elements; Unstable clinical presentation; Clinical decision making of high complexity; Typically, 45 minutes face-to-face
97164	Re-evaluation of physical therapy established plan of care, requiring an examination including a review of history and use of standardized tests and measures; Revised plan of care using standardized patient assessment instrument and/or measurable assessment of functional outcome; Typically, 20 minutes face-to-face
97165	Occupational therapy evaluation, low complexity, requiring components including an occupational profile and medical/therapy history; assessment identifying 1-3 performance deficits; Clinical decision making of low complexity; Typically, 30 minutes face-to-face
97166	Occupational therapy evaluation, moderate complexity, requiring components including an expanded occupational profile and history; assessment identifying 3-5 performance deficits; Clinical decision making of moderate analytic complexity; Typically, 45 minutes face-to-face
97167	Occupational therapy evaluation, high complexity, requiring components including extensive review of history; assessment identifying 5 or more performance deficits; Clinical decision making of high analytic complexity; Typically, 60 minutes face-to-face
97168	97168 (listed in policy)
97010	Hot or cold packs (application of a modality to 1 or more areas)
97012	Traction, mechanical (application of a modality to 1 or more areas)

1–10 of 41

1/5

PT & OT Modalitiesmixed

97010	Application of a modality to 1 or more areas; hot or cold packs.
97012	Application of a modality to 1 or more areas; traction, mechanical.
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended).
97016	Application of a modality to 1 or more areas; vasopneumatic devices.
97018	Application of a modality to 1 or more areas; paraffin bath.
97022	Application of a modality to 1 or more areas; whirlpool.
97024	Application of a modality to 1 or more areas; diathermy (eg, microwave).
97026	Application of a modality to 1 or more areas; infrared.
97028	Application of a modality to 1 or more areas; ultraviolet.
97032	Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes.

1–10 of 28

1/3

Therapy session length

Session length (PT)Up to 1 hour per physical therapy session (treatment and/or evaluation)

Session length (OT)Up to 1 hour per occupational therapy session (treatment and/or evaluation)

Multiple modalitiesUp to 3 PT modalities may be provided on any given day

Therapy time units

Typical billing incrementMany CPT/HCPCS therapy and modality codes are billed per 15-minute increments

Examples (15-min codes)97110, 97112, 97032, 97033, 97034, 97035, 97130, 97140, 97530, 97535, 97542, 97750, 97755

Authorization, Documentation, and Billing Requirements

Prior Authorization

Prior Authorization Required

Authorization will be required for all physical and occupational therapy services. Neighborhood has partnered with Evolent Health to manage prior authorizations for physical medicine services.

Documentation Required

Documentation Requirements

Members must have an order for outpatient therapy from a 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 on the claim. Services must relate to a written treatment plan (plan of care) established prior to treatment and documented in the medical record. Neighborhood reserves the right to request medical records for any billed service; documentation must support the services billed and medical necessity. Records must be retained in accordance with Rhode Island state and federal regulations. Neighborhood follows CMS standards for outpatient rehabilitation therapy documentation requirements.

Written treatment plan must include: diagnoses; short- and long-term goals; type of therapy; specific interventions/procedures/modalities; amount (sessions per day); duration (weeks or total sessions); frequency (sessions per week).

Key Definitions and Selected Code Notes

Physical Therapy — key points

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

Primary goalsRestore or improve function, reduce pain, increase mobility and independence

ProvidersServices performed by contracted Physical Therapists or contracted therapy groups to be reimbursed

Occupational Therapy — key points

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

Focus areas

Clinical Background

Physical therapy uses therapeutic exercise and other interventions to address disease or injury with the goals of improving mobility, strength, balance, coordination, joint mobility, flexibility, activities of daily living (ADLs), and reducing pain. Occupational therapy employs goal‑directed tasks and activities to improve functional performance related to neuromusculoskeletal or psychological dysfunction; both disciplines are focused on restoring or improving the member’s functional abilities.

Document History and Policy Changes

2026-01-01Annual ReviewLatest

Updated policy template to include new lines of business; updated prior authorizations, member responsibility and disclaimer language; updated documentation requirements to align with CMS.

2025-03-19Annual Review

Updated policy name to remove 'Rehabilitation'; updated coverage exclusions; added documentation requirements.

2025-03-01

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Physical and Occupational Therapy Services Coverage Criteria

Policy CodePolicy N/A

Change TypeDocumentation and authorization language updatedtemplate/admin updates

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization through Evolent Health for all outpatient PT and OT services before submitting claims.

SourceLink

On This Page

Unlisted or per-visit codesSome codes are unlisted or per visit (eg, 97139 unlisted therapeutic procedure; S9117 back school, per visit)

Ordering/referring provider must be recorded in the medical record and Box 17 on the claim.

Neighborhood may request medical records to validate billed services and medical necessity; retain records per state and federal regulations.

Billing Rule

Required Billing Modifiers

Certain CPT/HCPCS codes must be billed with a discipline modifier to identify whether the service was provided under an outpatient PT or OT plan of care. If a required modifier is not appended, the claim will deny. When services are furnished in whole or in part by therapy assistants, specific assistant modifiers are required and will be applied per CMS reimbursement rules.

GO – Services delivered under an outpatient OT plan of care (required to distinguish discipline).
GP – Services delivered under an outpatient PT plan of care (required to distinguish discipline).
CO – Occupational therapy services furnished in whole or in part by an occupational therapy assistant (OTA).
CQ – Outpatient physical therapy services furnished in whole or in part by a physical therapy assistant (PTA).
Missing required discipline or assistant modifier will cause claim denial; Neighborhood applies CMS reimbursement rules to these modifiers for all lines of business.

Denial Risk

Denial Risk Triggers

Claim payment is subject to member benefit coverage, eligibility, claims payment edits, correct coding and documentation, prior authorization requirements, provider contract terms, and applicable state and federal regulations. Providers should ensure authorizations are obtained, documentation is complete and retained, and required modifiers are appended to avoid denials or recoupments. All services billed are subject to audit.

Claims may be denied or adjusted for lack of authorization, missing or insufficient documentation, incorrect coding, missing modifiers, ineligibility, or contractual limitations.
Neighborhood may process claims differently across systems; verify system-specific requirements and timely filing rules per contract.
All services billed to Neighborhood are subject to audit and review for medical necessity and documentation compliance.

Improving performance in activities of daily living (ADLs), self-care, and work-related tasks through task-specific training and adaptive strategies

DocumentationServices must relate to a written treatment plan/plan of care with diagnoses, goals, interventions, amount, duration, and frequency

97130 — Therapeutic interventions (cognitive)

Code97130

DescriptionTherapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks); direct one-on-one patient contact; each additional 15 minutes (listed separately in addition to code for primary procedure).

Billing noteBilled per 15-minute increment as an add-on to primary therapeutic procedures

97139 — Unlisted therapeutic procedure

Code97139

DescriptionUnlisted therapeutic procedure — specify type of procedure when billed.

Billing noteWhen using 97139, provide documentation specifying the procedure performed to support medical necessity and reimbursement

97140 — Manual therapy techniques

Code97140

DescriptionManual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions; billed per 15 minutes.

Billing noteReport 97140 in 15-minute time units; documentation should identify regions treated and manual techniques used

Authorization Update

Updated authorization language for INTEGRITY line of business.

2024-06-01Annual Review

Updated authorization language for Medicaid and Commercial lines of business; added CO/CQ modifier reimbursement language effective 2024-07-15.

2023-10-01Authorization Update

Updated visit limits and authorization requirement language for INTEGRITY.

2023-03-29Annual Review

Annual review performed with no content changes.

2023-01-01Effective Date Change

Effective date for update to INTEGRITY to remove language around authorization requirement after 24 visits.

2022-02-01Policy Update

Added requirement to include referring provider information.

2021-04-01Policy Update

Removed limit of 24 visits for Medicaid and Commercial lines of business effective 2021-04-01.

2021-01-01Policy Updates

Commercial and INTEGRITY benefit limits and authorization requirements updated; Medicaid limit changed from rolling year to calendar year.

2020-11-05Review/Approval

Policy review and approval in preparation for 1/1/21 changes.

2020-10-01Effective Date

Policy went into effect.