CurrentPremera BluecrossPolicy N/A

Physical Medicine and Rehabilitation Services — billing limits, unit rules, and modifier requirements

Defines Premera Blue Cross limits, billing rules, and modifier requirements for physical, occupational and speech therapy services billed on professional (CMS-1500/837P) claims; applies to Premera and affiliated lines of business and their providers.

Policy Summary

PayerPremera Bluecross

PolicyPhysical Medicine and Rehabilitation Services — billing limits, unit rules, and modifier requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2000

Next Review DateN/A

Key ActionBill PTA/OTA services on the supervising therapist's claim line with CQ/CO and append the plan of care modifier (GP/GO) as required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

max 1 unitSupervised modality units per provider per date of service

max 2 unitsConstant attendance modality units per provider per date of service

max 4 unitsTherapeutic procedure units per provider per date of service

1 unitEvaluation/re-evaluation units per provider per date of service

15-min = 8 minTimed code billing halfway rule

Coverage criteria and billing requirements

When services are covered by member benefits and clinically appropriate, the Plan applies the following unit limits, billing rules and modifier requirements.

Services must be covered by member benefits and clinically appropriate.

ALL of the following

Supervised modalities (CPT 97012–97028): maximum of 1 unit per provider per single date of service.
Constant attendance modalities (CPT 97032–97039): maximum of 2 units per provider per single date of service.
Therapeutic procedures (CPT 97110–97124, 97129–97130, 97139–97140, 97530, 97760–97763): maximum of 4 units per provider per single date of service.

Policy Summary

PayerPremera Bluecross

PolicyPhysical Medicine and Rehabilitation Services — billing limits, unit rules, and modifier requirements

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateNov 1, 2000

Next Review DateN/A

Key ActionBill PTA/OTA services on the supervising therapist's claim line with CQ/CO and append the plan of care modifier (GP/GO) as required.

SourceLink

On This Page

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.

ALL of the following

Physical Therapy Assistant (PTA) and Occupational Therapy Assistant (OTA) services must be billed by the supervising licensed Physical Therapist or Occupational Therapist (services are NOT billed by the PTA/OTA).
When PTA/OTA services are provided in whole or in part, the line reporting those services (line two) must include the appropriate therapy assistant modifier (CQ for PTA or CO for OTA) and the appropriate plan of care modifier (GP or GO).
The supervising therapist (line one) must append the appropriate plan of care modifier (GP or GO).
If the PTA or OTA rendered the entire service and the supervising therapist did not render any part of the service, the supervising therapist bills one line for the service appended with the appropriate therapy assistant modifier (CQ or CO) and plan of care modifier (GP or GO).

Provider billing and modifier actions

Billing Rule

Provider billing limits and modifier requirements

When billing outpatient PT/OT/rehabilitation services, follow the Plan’s per‑provider, per‑date‑of‑service unit limits and modifier requirements exactly as stated. Supervised modality codes are limited to a maximum of 1 unit per provider per date of service; constant attendance modality codes are limited to a maximum of 2 units per provider per date of service; therapeutic procedure timed codes are limited to a maximum of 4 units per provider per date of service; and evaluation/re‑evaluation (97161‑97168) is limited to 1 unit per provider per date of service. PTA/OTA services must be billed by the supervising therapist with the appropriate assistant modifiers (CQ for PTA, CO for OTA) and include the plan of care modifier (GP/GO) as required.

Bill supervised modality codes (e.g., 97012–97028) no more than 1 unit per provider per DOS.
Bill constant attendance modality codes (e.g., 97032–97039) no more than 2 units per provider per DOS.
Bill therapeutic procedure timed codes (e.g., 97110–97124, 97129–97130, 97139–97140, 97530, 97760–97763) no more than 4 units per provider per DOS.
Bill evaluations/re‑evaluations (97161–97168) as a single unit per provider per DOS.
When PTA/OTA deliver services, the supervising licensed PT/OT must bill the service using the assistant modifier (CQ for PTA, CO for OTA) and include the plan of care modifier (GP/GO).

Modifier definitions

GP/GO/GN — Plan of Care Modifiers

GPModifier GP — Services delivered under an outpatient physical therapy plan of care; must be appended to 'always therapy' codes and placed after any reimbursement modifier.

GOModifier GO — Services delivered under an outpatient occupational therapy plan of care; must be appended to 'always therapy' codes and placed after any reimbursement modifier.

GNModifier GN — Services delivered under an outpatient speech-language pathology plan of care; must be appended to 'always therapy' codes and placed after any reimbursement modifier.

Application notePlan of care modifiers are required for CMS 'always therapy' designated codes regardless of who performs the service; review the Annual Therapy Code List for specifics.

CQ (PTA) and CO (OTA) — Therapy assistant modifiers

CQ (PTA)CQ — Outpatient physical therapy services furnished in whole or in part by a physical therapy assistant; services rendered by a PTA must be billed by the supervising PT and the PTA line appended with CQ and the plan of care modifier (GP/GO).

CO (OTA)CO — Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant; services rendered by an OTA must be billed by the supervising OT and the OTA line appended with CO and the plan of care modifier (GP/GO).

Billing formatPTA/OTA services are billed on two claim lines: line one for the supervising therapist (with plan of care modifier), line two for the PTA/OTA (with CQ or CO and plan of care modifier); if the PTA/OTA rendered the entire service and the supervisor did not participate, a single line may be billed by the supervising therapist with CQ or CO and the plan of care modifier.

OpenPayer

Physical Medicine and Rehabilitation Services — billing limits, unit rules, and modifier requirements

Coverage criteria and billing requirements

Therapy codes and timing rules

Provider billing and modifier actions

Modifier definitions