CurrentPremera BluecrossPolicy N/A

Physical Medicine and Rehabilitation services unit and billing limits

Defines Premera Blue Cross limits, billing, and modifier requirements for physical medicine, occupational, and speech therapy services on professional claims; applies to Premera and affiliated lines of business and products.

Policy Summary

PayerPremera Bluecross

PolicyPhysical Medicine and Rehabilitation services unit and billing limits

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2000

Next Review DateNov 4, 2025

Key ActionDirect questions about policy contents or application to the Payment Integrity Department.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1max supervised modality units / DOS / provider

2max constant attendance units / DOS / provider

4max therapeutic procedure units / DOS / provider

1eval/re-eval units / DOS / provider

815-min midpoint minutes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria and billing rules

When services are covered by member benefits and are clinically appropriate, the Plan applies these limits and billing rules:

Supervised modalities (CPT 97012-97028): maximum 1 unit per date of service, per provider.

Constant attendance modalities (CPT 97032-97039): maximum 2 units per date of service, per provider.

Therapeutic procedures (CPT 97110-97124, 97129-97130, 97139-97140, 97530, 97760-97763): maximum 4 units per date of service, per provider.

Physical and occupational therapy evaluations and re-evaluations (CPT 97161-97168): maximum 1 unit per date of service, per provider.

Timed code unit thresholds: For 15‑minute codes a unit is billable when incurred skilled time exceeds 8 minutes (billable unit = 8–22 minutes or multiples thereof); for 30‑minute codes a unit is billable when incurred skilled time exceeds 16 minutes (billable unit = 16–45 minutes or multiples thereof).

Modifier 52 (reduced services) is not recognized with timed modality or therapeutic services.

Plan of care modifiers (GN/GO/GP) must be appended to 'always therapy' codes as defined by the CMS Annual Therapy Update; these modifiers must be appended by any provider who renders one of the designated 'always therapy' codes and should be appended after any reimbursement modifier.

Physical/Occupational Therapy Assistant (PTA/OTA) billing rules: PT/OT assistant‑provided services must be billed by the supervising licensed therapist on two claim lines when the assistant provided services in whole or in part: line one — supervising therapist services with appropriate plan of care modifier (GP or GO); line two — PTA/OTA services appended with the assistant modifier (CQ or CO) and the appropriate plan of care modifier (GP or GO). If the assistant rendered the entire service and the supervising therapist did not render any part, the supervising therapist will bill one line appended with the assistant modifier (CQ or CO) and the appropriate plan of care modifier (GP or GO).

Claim and enforcement notes: Policy applies to professional services billed on CMS‑1500/837P and is subject to member eligibility, benefit limits, and claim adjudication edits. Violations of this policy may result in increased auditing and monitoring, contractual penalties, or termination; exceptions may be made when an employer group's benefits dictate otherwise.

Therapy, modality, and timed-code coding guidance

Supervised modality CPT codesCPT

97012-97028

Supervised modalities (examples listed in policy)

Constant attendance modality CPT codesCPT

97032-97039

Constant attendance modalities (examples listed in policy; includes 97037 effective Jan 1, 2024)

Therapeutic procedure CPT codesCPT

97110-97124,97129-97130,97139-97140,97530,97760-97763

Therapeutic procedures (timed codes listed in policy)

Physical and occupational therapy evaluation CPT codesCPT

97161-97168

Physical and occupational therapy evaluations and re-evaluations

Speech therapy CPT codesCPT

92507-92508,92521-92524

Speech therapy treatment and evaluation codes

Timed code unit thresholds

15-minute codes (per CPT midpoint)A unit is billable when elapsed skilled time exceeds 8 minutes (halfway point); a single 15-minute unit = 8–22 minutes; multiples follow these increments.

30-minute codes (per CPT midpoint)A unit is billable when elapsed skilled time exceeds 16 minutes (halfway point); a single 30-minute unit = 16–45 minutes; multiples follow these increments.

Billing increments ruleUnits are determined by CPT time‑midpoint rules — billable time ranges are the midpoint through the next multiple (e.g., 8–22 minutes for one 15‑minute unit); multiples of the increment are allowed.

Non‑recognition of modifier 52Modifier 52 (reduced services) is not recognized with timed modality or therapeutic services.

Modifiers and assistant billing definitions

Plan of care modifiers (GP, GO, GN)

GPServices delivered under an outpatient physical therapy plan of care; append to 'always therapy' codes when furnished under a PT plan.

GOServices delivered under an outpatient occupational therapy plan of care; append to 'always therapy' codes when furnished under an OT plan.

GNServices delivered under an outpatient speech‑language pathology plan of care; append to 'always therapy' codes when furnished under an SLP plan.

Therapy assistant modifiers (CQ/CO) and billing practice

CQ (PTA)Indicates outpatient physical therapy services furnished in whole or in part by a physical therapy assistant; must be appended to the PTA line on the claim.

CO (OTA)Indicates outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant; must be appended to the OTA line on the claim.

Contact and escalation

Note

Contact for policy questions

Any questions regarding the contents of this policy or its application should be directed to the Payment Integrity Department.