CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Outpatient Physical and Occupational Therapy Reimbursement

This payment policy governs coverage, billing, and reimbursement rules for outpatient physical therapy (PT) and occupational therapy (OT) services for Neighborhood Health Plan of Rhode Island membership across Medicaid, INTEGRITY, and Commercial products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOutpatient Physical and Occupational Therapy Reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member eligibility and obtain prior authorization when additional PT/OT sessions beyond product-specific limits are needed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24Medicaid PT annual limit (rolling year)

24Medicaid OT annual limit (rolling year)

8INTEGRITY & Commercial initial sessions

90Claims timely filing (days)

1Typical session duration (hrs)

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Coverage Criteria

Core Coverage Criteria

Coverage is conditioned on a written treatment plan, medical necessity, and performance by contracted therapists.

ALL of the following

Written treatment plan (plan of care) established by a physician, NPP, physical therapist, or occupational therapist
The plan must record the signature and professional identity of the person who established it and the date it was established; see certification timelines below.
ALL of the following
- Services are intended to restore function or provided as 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 must be considered safe and effective for the patient’s condition and be medically necessary
Neighborhood may use NCD, LCD, InterQual, EOHHS recommendations, and Clinical Medical Policies to determine medical necessity.
Services must be performed by a contracted Physical or Occupational Therapist or contracted therapy group to be reimbursed
ALL of the following
- The established treatment plan requires physician/NPP certification for the duration of the treatment plan or 90 calendar days from the date of initial treatment, whichever is less.
- Timely certification of the initial treatment plan is met when physician/NPP certification (signature or verbal order) is documented and dated within 30 days following the first day of treatment (including evaluation).
- Verbal orders must be followed within 14 days by a signature and date.
- Recertification must be signed whenever a significant modification of the treatment plan is needed, or at least every 90 days after initiation of treatment.

ALL of the following

Diagnoses
Type of rehabilitation therapy services (physical and/or occupational)
Short- and long-term treatment goals
Identification of each intervention, procedure, or modality to support coding and billing
Duration (number of weeks or number of treatment sessions)
Amount (number of treatment sessions in a therapy day)

Product Limits

Product-specific session limits and authorization requirements.

ANY of the following

ALL of the following
- Physical Therapy is covered without prior authorization and is limited to 24 sessions per prior rolling year.
- Occupational Therapy is covered without prior authorization and is limited to 24 sessions per prior rolling year.
ALL of the following
- Physical Therapy: covered without prior authorization for the initial evaluation plus 8 PT sessions per calendar/plan year; additional sessions require prior authorization.
- Occupational Therapy: covered without prior authorization for the initial evaluation plus 8 OT sessions per calendar/plan year; additional sessions require prior authorization.

Exclusions

Services explicitly excluded from coverage.

ANY of the following

General conditioning programs
Services provided solely for the convenience of the member or service provider
Vocational rehabilitation, including services focused on job adaptability, job placement, or rehabilitative services to restore function for a member's specific occupation

Coding and Service Definitions

PT & OT Evaluation and Re-Evaluation (CPT)CPTCovered

97161	Physical therapy evaluation: low complexity; typically 20 minutes face-to-face; history, exam, and low complexity clinical decision making.
97162	Physical therapy evaluation: moderate complexity; typically 30 minutes face-to-face; expanded history/exam and moderate complexity clinical decision making.
97163	Physical therapy evaluation: high complexity; typically 45 minutes face-to-face; comprehensive history/exam and high complexity decision making.
97164	Re-evaluation of established physical therapy plan of care; includes review of history and standardized tests with revised plan of care.
97165	Occupational therapy evaluation: low complexity; typically 30 minutes face-to-face; occupational profile, assessments identifying 1-3 performance deficits, low complexity decision making.
97166	Occupational therapy evaluation: moderate complexity; typically 45 minutes face-to-face; expanded history, assessments identifying 3-5 deficits, moderate complexity decision making.
97167	Occupational therapy evaluation: high complexity; typically 60 minutes face-to-face; extensive history, assessments identifying 5+ deficits, high complexity decision making.
97168	Re-evaluation of occupational therapy established plan of care; assessment of changes, revised plan of care; typically 30 minutes face-to-face.

PT & OT Modalities and Therapeutic Procedures (CPT/HCPCS)mixedCovered

97010	Hot or cold packs; application to one or more areas.
97012	Traction, mechanical; application to one or more areas.
97014	Electrical stimulation (unattended); application to one or more areas.
97016	Vasopneumatic devices; application to one or more areas.
97018	Paraffin bath; application to one or more areas.
97022	Whirlpool; application to one or more areas.
97024	Diathermy (e.g., microwave); application to one or more areas.
97026	Infrared; application to one or more areas.
97028	Ultraviolet; application to one or more areas.
97032	Electrical stimulation (manual), each 15 minutes; application to one or more areas.

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Session Definition and Daily Modality Limit

Physical/Occupational therapy session durationTypically defined as up to 1 hour of treatment and/or evaluation per therapy day.

Daily modality limitUp to 3 PT modalities may be provided on any given day (constant attendance modalities counted per policy).

Other short definitionsUnlisted modality (97039) — specify type and time; Re-evaluations (97164, 97168) — performed when documented change in functional status or significant change to plan of care is required.

Provider Actions, Billing & Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization Required for Additional Sessions: For Medicaid, Integrity, and Commercial products, initial evaluation and a limited number of therapy sessions are covered without prior authorization; additional sessions require prior authorization. Providers must verify product-specific limits and obtain authorization before rendering services beyond the authorization-free allowance.

Medicaid: PT = 24 sessions prior rolling year; OT = 24 sessions prior rolling year.
Integrity & Commercial: initial evaluation + 8 PT sessions per calendar/plan year without authorization; additional PT sessions require prior authorization.
Integrity & Commercial: initial evaluation + 8 OT sessions per calendar/plan year without authorization; additional OT sessions require prior authorization.

Documentation Required

Treatment Plan Documentation Requirements

Written treatment plan / plan of care must be maintained in the medical record and include required elements. The treatment plan must show the signature and professional identity of the person who established it and the date. The plan requires physician or NPP certification for the duration of the plan or 90 calendar days from the initial treatment date, whichever is less. Verbal orders must be countersigned within 14 days. Recertification is required whenever significant changes are made or at least every 90 days.

Definitions

Physical Therapy

Physical Therapy (PT)Treatment using therapeutic exercise and other interventions to improve posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility and alleviate pain.

Primary focusImprove functional activities of daily living through therapeutic interventions

Typical componentsTherapeutic exercise, manual therapy, modalities and functional training

Occupational Therapy

Occupational Therapy (OT)Rehabilitation therapy involving treatment of neuro‑musculoskeletal and psychological dysfunction through specific tasks or directed activities designed to improve an individual’s functional performance.

Primary focusEnhance independence in daily activities via task‑directed interventions