CurrentNew York State Department of HealthPolicy N/A

Rehabilitation Services Policy Guidelines

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New York State Medicaid requirements for ordering, participation, documentation, medical necessity, and treatment sessions for restorative and long-term physical, occupational, and speech therapy services.

Policy Summary

PayerNew York State Department of Health

PolicyRehabilitation Services Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionOrder rehabilitation services in writing through an authorized physician, physician assistant, or nurse practitioner.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Therapy disciplines

9Medical-necessity conditions

4Procedure modifiers

3Ordering practitioner types

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CurrentNew York State Department of HealthPolicy N/A

Rehabilitation Services Policy Guidelines

Customize your policy alerts

Sign up for all New York State Department of Health policy alerts

Know when New York State Department of Health releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNew York State Department of Health

PolicyRehabilitation Services Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionOrder rehabilitation services in writing through an authorized physician, physician assistant, or nurse practitioner.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Therapy disciplines

9Medical-necessity conditions

4Procedure modifiers

3Ordering practitioner types

Documentation contexts

Medical Necessity and Coverage Criteria

Restorative or long-term therapy medical necessity

Restorative or long-term physical, occupational, or speech therapy services are medically necessary when all of the following are met.

Medical necessity requirements

Qualified skilled service: The therapy services require the skills of, and are delivered by, a qualified practitioner.
Evaluation and measurable plan: The beneficiary has been evaluated or reevaluated for continuation of therapy services and has an established treatment plan with reasonable and attainable goals that can be objectively measured using standardized or nonstandardized measures and tools.
Clinical condition and directed intervention: The beneficiary has an identifiable clinical condition or diagnosis, is symptomatic, and interventions are directed at preventing disability or regression, or improving, adapting, or restoring functions impaired or lost due to a specific illness, injury, neurodevelopmental disease or condition, surgery, loss of a body part, or congenital abnormality.
Skilled need and unmet benefit: Therapeutic benefit has not been reached, and interventions require the unique knowledge, skills, and judgment of a qualified practitioner and cannot or have not been met by a comprehensive maintenance services program or home program.
Rehabilitation potential and expected outcome: Based on rehabilitation potential, there is a reasonable expectation that interventions will result in objective or measurable functional outcomes within a reasonable and predictable period, and outcomes are documented in the beneficiary's file.
Non-routine treatment: Treatments are not routine education, training, conditioning, or fitness, and the beneficiary's function could not reasonably be expected to improve merely by gradually resuming normal activities.
No duplicate therapy: Treatments are not duplicate therapy.
Non-recreational purpose: Treatments are not solely recreational, including hobbies or arts and crafts.
Beneficiary participation: The beneficiary has not refused therapy.

Medical necessity for restorative or long-term therapy

Restorative or long-term physical, occupational, or speech therapy services are medically necessary when ALL of the following are met.

All medical necessity requirements

Qualified skilled service: The therapy services require the skills of, and are delivered by, a qualified practitioner.
Evaluation and treatment plan: The beneficiary has been evaluated or reevaluated for continuation of therapy services and has an established treatment plan with reasonable and attainable goals that can be objectively measured using standardized or nonstandardized measures and tools.
Identifiable symptomatic condition and targeted function: The beneficiary has an identifiable clinical condition or diagnosis, is symptomatic, and the interventions are directed at preventing disability or regression, or improving, adapting, or restoring functions impaired or lost because of a specific illness, injury, neurodevelopmental disease or condition, surgery, loss of a body part, or congenital abnormality.

Excluded services include routine education, training, conditioning, or fitness; solely recreational activities such as hobbies or arts and crafts; duplicate therapy; and therapy refused by the beneficiary. Services also do not meet the skilled-therapy coverage criteria when therapeutic benefit has been reached or when the need can be met through a comprehensive maintenance services program or home program.

Routine education, training, conditioning, or fitness is excluded when the beneficiary's function could reasonably be expected to improve through gradually resuming normal activities.

Duplicate therapy is excluded from coverage criteria.

Therapy that is solely recreational, including hobbies or arts and crafts, is excluded.

Therapy refused by the beneficiary is excluded from the coverage criteria.

Services do not satisfy the skilled-therapy coverage criteria when they can be met through a comprehensive maintenance services program or home program, or when therapeutic benefit has been reached.

Therapy is not medically necessary when therapeutic benefit has been reached, the need can be met through a comprehensive maintenance or home program, the intervention does not require the unique knowledge, skills, and judgment of a qualified practitioner, or there is no reasonable expectation of objective or measurable functional outcomes within a reasonable and predictable period.

Rehabilitation Procedure Modifiers

Modifiers for Rehabilitation ProceduresModifier

GP	Services delivered under an outpatient physical therapy plan of care.
GO	Services delivered under an outpatient occupational therapy plan of care.
GN	Services delivered under an outpatient speech-language pathology plan of care.
ST	Services delivered to a patient with a traumatic brain injury (TBI) (as defined in Public Health Law Article 27-cc: § 2741)

Ordering, Documentation, and Coverage Risk

Documentation Required

Written Order or Speech Referral

Obtain a written order for rehabilitation services from a physician, physician assistant, or nurse practitioner authorized by law. Speech therapy may also be provided based on a written referral from a speech-language pathologist authorized by law.

Written orders are required for PT, OT, and speech therapy services.
Speech-language-pathologist referrals apply specifically to speech therapy.

Documentation Required

Professional Record-Keeping Standards

Maintain qualifying documentation in accordance with the applicable clinician’s professional-organization standards, in addition to the general record-keeping requirements for all providers.

Follow applicable APTA, AOTA, or ASHA documentation standards.
Professional standards apply in addition to general Medicaid record-keeping requirements.

Therapy Service Framework

Restorative therapy requires licensed-practitioner expertise, diagnostic evaluation, and therapeutic intervention to improve, develop, correct, or rehabilitate physical functions that are lost, impaired, or reduced by an acute or chronic condition, congenital abnormality, or injury. Its purpose is to achieve individualized, relevant, transferable, and objectively measurable functional improvement.

Key Policy Definitions

Duplicate therapy

DefinitionThe same therapy service(s) and/or treatment(s) provided by more than one therapy type, or the same discipline in different settings.

Documentation distinctionAbsent unique circumstances, each specific discipline or same discipline in a different setting should be documented in the medical record with a unique and specific evaluation, treatment plan, goals, and therapeutic interventions.

Evaluation

DefinitionAn assessment of the beneficiary's physical and functional status used to determine whether PT, OT, or ST services are medically necessary.

Required informationThe evaluation gathers baseline data, including objective findings, and establishes a treatment plan with reasonable and attainable goals within a defined period of time.

Measures and timing

Policy Summary

PayerNew York State Department of Health

PolicyRehabilitation Services Policy Guidelines

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionOrder rehabilitation services in writing through an authorized physician, physician assistant, or nurse practitioner.

SourceLink

On This Page

Skilled benefit not reached: Therapeutic benefit has not been reached, and the interventions address conditions requiring the unique knowledge, skills, and judgment of a qualified practitioner that cannot or have not been met by a comprehensive maintenance services program or home program.

Expected measurable outcome: Based on the beneficiary's rehabilitation potential, there is a reasonable expectation that the interventions will result in objective or measurable functional outcomes within a reasonable and predictable period, and the outcomes are documented in the beneficiary's file.

Treatment is not routine conditioning or fitness: The treatments are not routine education, training, conditioning, or fitness, and the beneficiary's function could not reasonably be expected to improve merely by gradually resuming normal activities.

No duplicate therapy: The treatments are not duplicate therapy.

Not solely recreational: The treatments are not solely recreational, such as hobbies or arts and crafts.

Beneficiary has not refused therapy: The beneficiary has not refused therapy.

Documentation Required

Evaluation and Treatment-Plan Documentation

Before implementing any treatment plan, complete an evaluation establishing medical necessity, baseline findings, diagnosis or clinical condition, and a plan of care with reasonable and attainable measurable goals.

Assess the beneficiary’s physical and functional status using appropriate standardized or nonstandardized assessments, objective measures, and tools.
Document the identifiable clinical condition or diagnosis and relevant symptoms.
Record baseline findings and objective, measurable, functional deficits.
Document clinical reasoning and recommendations.
Establish treatment techniques or activities, frequency, duration, and functional, measurable, time-framed short- and long-term goals.
Ensure goals are reasonable and attainable for the beneficiary’s condition.
Document rehabilitation prognosis, expected degree of improvement, and a discharge plan initiated at the start of treatment.

Denial Risk

Distinguish Duplicate Therapy

When therapy could otherwise be considered duplicate, document each discipline or setting separately unless unique circumstances support a different approach. Each applicable discipline or setting must have its own medical-record documentation, evaluation, treatment plan, goals, and therapeutic interventions.

Duplicate therapy includes the same service or treatment provided by more than one therapy type, such as PT and OT or OT and speech therapy.
The same discipline delivered in different settings, such as school-based and home-based therapy, may also constitute duplicate therapy.
Document unique circumstances supporting separate or nonduplicative services.

Documentation Required

Treatment Session Must Support the Plan

Base each treatment session on the beneficiary’s specific medical condition and support it in the treatment plan. Sessions may include reassessment, skilled therapeutic procedures, functional training, device-related services, modalities used to prepare for skilled treatment, and beneficiary or caregiver training.

Reassess deficits, progress, rehabilitation potential, plan, and goals.
Provide therapeutic exercise, neuromuscular reeducation, coordination, balance, oral-motor, laryngeal, pharyngeal, or breathing exercises.
Provide functional-skills training; manual therapy; airway-clearance techniques; integumentary repair or protection; and positioning, eating, or swallowing management.
Assess, design, fabricate, apply, fit, and train beneficiaries in assistive technology, adaptive devices, orthotics, and prosthetic devices, including speech-generating devices.
Use electrotherapeutic, physical-agent, or mechanical modalities when preparing for other skilled treatment procedures.
Provide compensatory or adaptive communication or swallowing training and home-exercise, activity-program, or comprehensive-maintenance-program training.

Documentation Required

Reevaluation Documentation

A reevaluation must include all components of the initial evaluation and document whether continued skilled therapy remains appropriate, the beneficiary’s current problems, and the clinical basis for any ongoing or revised plan of care.

Discuss the appropriateness of continuing skilled therapy.
List current problems and determine treatment priority or focus.
Identify appropriate interventions for new or ongoing goals and modify interventions as needed.
Revise the plan of care when necessary.
Correlate findings to meaningful functional change.
Determine the effectiveness of interventions.

Documentation Required

Treatment-Session Documentation

Document every treatment session sufficiently to support the services billed and the beneficiary’s progress under the treatment plan.

Date of treatment.
Specific treatments provided, matching the procedure codes billed.
Total treatment time.
Beneficiary’s response to treatment.
Progress toward goals.
Problems or changes to the plan of care.
Name and credentials of the treating clinician.

Documentation Required

Professional Documentation Standards

The listed evaluation, reevaluation, and treatment-session elements are a general guideline and are not all-inclusive. In addition, documentation must follow the applicable standards of the clinician’s professional organization.

Apply relevant APTA, AOTA, or ASHA standards, as applicable.
Retain any additional documentation required by professional standards or other Medicaid requirements.

Denial Risk

Missing Skilled-Service or Clinical-Necessity Basis

Coverage is at risk when therapy does not require the unique knowledge, skills, and judgment of a qualified practitioner or is not delivered by one. The services must be supported by the beneficiary’s condition and an adequate medical-necessity foundation.

A qualified practitioner must have passed the necessary national examination, obtained state licensure, and practice within the scope of licensure.
Services must address a specific illness, injury, neurodevelopmental disease or condition, surgery, loss of a body part, or congenital abnormality.

Denial Risk

No Expected Measurable Benefit

Do not bill covered therapy when the expected therapeutic benefit has been reached or when the condition can be addressed through a comprehensive maintenance-services program or home program. Skilled interventions must reasonably be expected to produce objective, measurable functional outcomes within a reasonable and predictable period.

Document rehabilitation potential and expected functional improvement.
Document the objective or measurable outcomes in the beneficiary’s file.
Support why skilled therapy, rather than maintenance or home programming, is required.

Denial Risk

Excluded Treatment Purpose or Duplicate Therapy

Therapy is not covered when it is routine education, training, conditioning, or fitness; when function would reasonably be expected to improve through gradual resumption of normal activities; when it is solely recreational; when the beneficiary refuses therapy; or when it is duplicate therapy.

Do not rely solely on hobbies, arts and crafts, or other recreational activities as the treatment purpose.
Do not bill duplicate services across therapy types or settings.
Document that the beneficiary has not refused therapy.

Denial Risk

Duplicate Therapy

Treat the same therapy service or treatment as duplicate therapy when provided by more than one therapy type or by the same discipline in different settings, absent unique circumstances. Duplicate services may be denied unless the record supports distinct services and circumstances.

Examples include PT and OT, OT and speech therapy, or school-based and home-based therapy.
Document separate evaluations, treatment plans, goals, and therapeutic interventions for each discipline or setting when applicable.

Denial Risk

Unqualified Personnel

Only qualified practitioners may furnish covered therapy services, subject to the specifically permitted supervised roles. Certain personnel remain unqualified regardless of the level of supervision.

PT assistants and OT assistants may provide services under the direction and supervision of their respective therapists.
TSHH or TSSLD teachers employed by an eligible governmental, school, or higher-education entity may provide speech therapy under the direction of a qualified, currently registered New York State speech-language pathologist.
Aides, athletic trainers, exercise physiologists, life-skills trainers, special-education teachers, paraprofessionals, and rehabilitation technicians do not meet the qualified-practitioner definition, regardless of supervision.

Denial Risk

Missing Medical-Necessity Foundation

Coverage requires a medical-necessity foundation: qualified delivery, an evaluation or reevaluation, an established treatment plan with reasonable and attainable objectively measurable goals, and an identifiable symptomatic clinical condition.

Services must be directed at preventing disability or regression, or improving, adapting, or restoring function impaired or lost because of a specific illness, injury, neurodevelopmental disease or condition, surgery, loss of a body part, or congenital abnormality.
Document the evaluation or reevaluation, treatment plan, goals, and clinical rationale in the beneficiary’s file.

Denial Risk

No Expected Skilled Benefit

Do not bill ongoing skilled therapy when therapeutic benefit has been reached or when a comprehensive maintenance or home program can meet the beneficiary’s needs. There must be a reasonable expectation of objective, measurable improvement based on rehabilitation potential.

The interventions must require the unique knowledge, skills, and judgment of a qualified practitioner.
Document expected functional outcomes and the reasonable, predictable period for achieving them.
Support why maintenance services or a home program are insufficient.

Denial Risk

Excluded Treatment Purpose or Circumstance

Coverage is not supported for routine education, training, conditioning, fitness, solely recreational treatment, duplicate therapy, or therapy refused by the beneficiary. Services also must not be reasonably replaceable by gradual resumption of normal activities.

Do not bill services provided solely for hobbies, arts and crafts, or recreation.
Do not bill duplicate therapy across disciplines or settings.
Document the beneficiary’s participation and lack of refusal.

Denial Risk

Insufficient Treatment-Session Documentation

Incomplete treatment-session records create claim risk. The record must identify what was treated, support alignment with the procedure codes billed, and include the required clinical and timing details.

Record the treatment date and specific treatments provided.
Ensure treatments match the procedure codes billed.
Record total treatment time, beneficiary response, progress toward goals, and problems or changes to the plan of care.
Include the treating clinician’s name and credentials.

Evaluations use appropriate and relevant assessments with objective measures and/or tools and are required before implementing any treatment plan.

Long-term therapy services

DefinitionPhysical, occupational, and/or speech therapy services that require the knowledge or expertise of a licensed practitioner because of the beneficiary's unique physical, cognitive, or psychological status.

PurposeThe services maintain the beneficiary's physical and/or functional status.

Qualifying goalsGoals must prevent deterioration and sustain function, support the highest level of independence for chronic or progressive disability, and/or address progress that is slower than expected for restorative care.

Outcome standardOutcomes must be functional, individualized, relevant, and transferrable to the current or anticipated environment.

Modifier

DefinitionA two-digit code used to further define or explain the nature of a procedure.

Claim requirementThe appropriate modifier from Table 1 must be included on claims.

Claim purposeThe modifier identifies the specific type of therapy.

Qualified practitioner

Core requirementsA therapist who has passed the necessary national examination, obtained state licensure, and performs within the scope of licensure.

Professional standardsPractice is regulated by federal and state governments and defined by the appropriate professional organization, such as APTA, AOTA, or ASHA.

Assistant servicesPhysical Therapy assistants or Occupational Therapy assistants may provide services under the direction and supervision of their respective Physical or Occupational Therapist.

Speech therapy personnelCertified TSHH or TSSLD teachers employed by specified governmental, school, or higher-education entities may provide speech therapy under the direction of a qualified NYS licensed and currently registered speech-language pathologist.

Excluded personnelAides, athletic trainers, exercise physiologists, life skills trainers, special education teachers, paraprofessionals, and rehabilitation technicians do not meet the definition regardless of the level of supervision.

Re-evaluation

DefinitionAn assessment done to evaluate progress or to modify or redirect therapy services.

IndicationsA re-evaluation is performed when there are new clinical findings, a rapid change in status, or failure to respond to the therapeutic interventions.

Rehabilitation potential

DefinitionThe amount of improvement anticipated in a beneficiary in relation to the extent and duration of the therapy service provided.

Functional considerationIt includes consideration of previous functional status.

Clinical considerationIt includes consideration of the effects of the current condition or disease process.

Restorative therapy

DefinitionPhysical, occupational, and/or speech therapy services that require the knowledge or expertise of a licensed practitioner.

ComponentsServices include diagnostic evaluation and therapeutic intervention.

PurposeIntervention is designed to improve, develop, correct, or rehabilitate physical functions lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital abnormalities, or injuries.

Therapy services

DefinitionMedically necessary therapeutic activities and/or treatments provided by a qualified practitioner.

Provider requirementServices must be provided by a qualified practitioner as defined in the policy.

Medical-necessity requirementThe activities and/or treatments must be medically necessary.