CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Physical Therapy and Occupational Therapy coverage and billing policy

Defines medical necessity, coverage limits, supervision, billing modifiers, coding guidance, and exclusions for outpatient PT and OT services for Neighborhood Health Plan of Rhode Island across Medicaid (excluding EFP), KINTEGRITY, and Commercial lines.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Physical Therapy and Occupational Therapy coverage and billing policy

Policy CodePolicy N/A

Change TypeAdministrative review (no content changes)

Effective Date01/01/2023

Next Review DateN/A

Key ActionObtain and document a separate order for outpatient PT/OT from the PCP or treating qualified provider and include the referring provider on the medical record and claim (Box 17).

SourceLink

POLICY UPDATE CHANGES

Document history notes administrative reviews and prior updates; most recent 03/29/2023 annual review with no content changes.

24PT sessions limit per calendar year (INTEGRITY)

24OT sessions limit per calendar year (INTEGRITY)

1Typical maximum session length per PT or OT session

GO, GP, CQ, CORequired discipline/modifier codes

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Medical Necessity Criteria for Outpatient PT & OT

General medical necessity

Outpatient PT/OT services are covered when ALL of the following are met:

ALL of the following

Member has an order for outpatient services from the PCP or treating qualified provider separate from the rendering provider
Referring provider must be documented in the medical record and noted in Box 17 of the claim
Services relate directly and specifically to a written treatment plan (plan of care) established by a physician, NPP, PT, or OT
Services are considered safe and effective, consistent with nature/severity of illness, and 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 personnel
All services must be medically necessary
Neighborhood may use LCDs, NCDs, Interqual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity

Physical Therapy Assistant / Occupational Therapy Assistant supervision requirements

When PTA/OTA provide services in off-site settings under general supervision, the supervising therapist must meet ALL of the following:

ALL of the following

Physical/occupational therapist must be accessible by telecommunications to the assistant at all times while the assistant is treating patients/clients
Regularly scheduled and documented conferences between therapist and assistant, frequency determined by patient and assistant needs
On-site reexamination by supervising therapist upon assistant request, when change in plan of care is needed, at planned discharge, or in response to change in patient medical status
- ONE of

Coverage limits (INTEGRITY)

Limits applied to outpatient therapy under INTEGRITY line:

ALL of the following

Outpatient Physical Therapy limited to 24 sessions per calendar year
No authorization required
Outpatient Occupational Therapy limited to 24 sessions per calendar year
No authorization required

Session definition

How a therapy session is defined:

ALL of the following

A physical session: up to 1 hour of PT (treatment and/or evaluation) or up to 3 PT modalities on any given therapy dayUp to 1 hour; Up to 3 PT modalities
An occupational session: up to 1 hour of OT (treatment and/or evaluation) on any given therapy dayUp to 1 hour

Exclusions (Not covered)

Services not eligible for reimbursement:

ANY of the following

General conditioning programs
Rehabilitative services to restore function for a member's occupation-specific duties (vocational rehabilitation)
Vocational rehabilitation and screening focused on job adaptability and placement testing
Services provided solely for the convenience of the member or service provider

Relevant CPT/HCPCS Codes and Modifiers

Evaluation and Re-evaluation CPT codes (PT & OT)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
97167	Occupational therapy evaluation, high complexity
97168	Re-evaluation of occupational therapy established plan of care

PT & OT Modalities and Therapeutic ProceduresCPT|HCPCS

97010	Hot or cold packs
97012	Traction, mechanical
97014	Electrical stimulation (unattended)
97016	Vasopneumatic devices
97018	Paraffin bath
97022	Whirlpool
97024	Unspecified in text (presumed modality)
97026	Infrared
97028	Ultraviolet
97032	Electrical stimulation (manual), each 15 minutes

1–10 of 33

1/4

Required discipline/provider modifiersModifier

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

Billing, Documentation, and Authorization Requirements

Documentation Required

Referring provider documentation

Order for outpatient services must come from the member’s PCP or treating qualified provider who is separate from the rendering provider and this referring/provider order must be documented in the member’s medical record and noted in Box 17 (referring provider) on the claim.

Documentation Required

Plan of care requirement

Outpatient PT/OT services must relate directly and specifically to a written treatment plan (plan of care) established by a physician, NPP, physical therapist, or occupational therapist; the plan of care must be maintained in the member’s medical record.

Prior Authorization

Authorization for services

Clinical and Administrative Background

Physical therapy (PT) and occupational therapy (OT) are rehabilitative services that employ therapeutic exercise, modalities, and task‑oriented interventions to improve strength, mobility, function, activities of daily living, and to reduce pain. PT focuses on posture, locomotion, strength, endurance, balance, coordination, joint mobility and flexibility, while OT addresses neuromusculoskeletal and psychological dysfunction through specific tasks or directed activities to improve functional performance.

Coverage for outpatient PT and OT services is contingent on medical necessity and documentation of an appropriate plan of care. Members must have an order for outpatient services from their PCP or another treating qualified provider (separate from the rendering provider) that is documented in the medical record and noted on the claim (Box 17).

Services must relate directly and specifically to a written treatment plan (plan of care) established by a physician, NPP, PT, or OT and must be safe, effective, consistent with the nature and severity of the illness, and 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.

Providers are expected to perform services by contracted PTs/OTs or contracted therapy personnel and to document medical necessity using applicable LCDs, NCDs, Interqual, EOHHS recommendations, and Neighborhood Clinical Medical Policies as appropriate. This policy was last reviewed on 03/29/2023 with no clinical or coverage content changes identified.

Defined Terms

Definitions

SessionA therapy session is typically up to 1 hour of treatment and/or evaluation on any given therapy day.

Plan of care (plan of treatment)A written treatment plan established by a physician, NPP, PT, or OT that documents therapeutic goals, interventions, frequency, and duration tied to an acute or acute-on-chronic condition with potential for functional recovery.

Policy Change Summary

2023-03-29Annual review (administrative)Latest

Annual review completed with no clinical or coverage changes.

2023-01-01Policy update

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

2022-02-01Policy update

Updated to include requirement for documenting the referring provider.

Numeric and Operational Thresholds

Thresholds

Typical session lengthUp to 1 hour per PT or OT session

PT modalities per therapy dayUp to 3 PT modalities per therapy day

INTEGRITY annual visit limits24 sessions per calendar year for PT and 24 for OT