CurrentPremera BluecrossPolicy N/A

Physical Medicine and Rehabilitation services billing and unit limits

Defines Premera Blue Cross limits, billing, modifier and unit-counting rules for professional outpatient physical medicine and rehabilitation services (physical, occupational and speech therapy) submitted on professional claims; applies to Premera lines of business and affiliates.

Policy Summary

PayerPremera Bluecross

PolicyPhysical Medicine and Rehabilitation services billing and unit limits

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 1, 2000

Next Review DateN/A

Key ActionEnsure services are covered by member benefits and adhere to per-provider unit limits and modifier billing rules when submitting professional claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 unitmax supervised modality units / provider / DOS

2 unitsmax constant attendance units / provider / DOS

4 unitsmax therapeutic procedure units / provider / DOS

1 unitmax PT/OT eval or re-eval / provider / DOS

8 min15-min code halfway point

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Coverage limits and billing criteria

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

ALL of the following

Supervised modalities (CPT 97012-97028): maximum 1 unit per provider per date of service
Constant attendance modalities (CPT 97032-97039): maximum 2 units per provider per date of service
Therapeutic procedures (CPT 97110-97124,97129-97130,97139-97140,97530,97760-97763): maximum 4 units per provider per date of service
Physical/Occupational therapy evaluation and re-evaluation (CPT 97161-97168): one unit maximum per provider per date of service

ALL of the following

A unit may be billed only when the incurred time exceeds the 'halfway' point for the code's time increment
For 15-minute increment codes the halfway point is 8 minutes; billable unit range = 8-22 minutes (or multiples)
For 30-minute increment codes the halfway point is 16 minutes; billable unit range = 16-45 minutes (or multiples)

ALL of the following

Append appropriate plan-of-care modifier (GP for PT, GO for OT, GN for speech) to 'always therapy' codes as required
When PTA/OTA furnish services under direct supervision, the supervising licensed therapist must bill the services on two claim lines: supervisor line and assistant line with assistant modifier (CQ or CO) plus plan-of-care modifier (GP or GO)
If the assistant performed the entire service and the supervisor performed none, bill one claim line with CQ or CO plus GP/GO

ALL of the following

Violations of this policy may result in increased auditing, contractual penalties, and/or termination of contract; disciplinary actions determined by the plan
Exceptions may be made when a member's employer group benefits dictate otherwise

ALL of the following

See policy code lists for examples of supervised modality codes (97012-97028) and constant attendance and therapeutic procedure codes (97032-97039; 97110-97124,97129-97130,97139-97140,97530,97760-97763)
See evaluation/re-evaluation codes (97161-97168) and speech codes (92507-92508,92521-92524)

Operational provider action note

Ensure services are covered by member benefits and clinically appropriate; adhere to per-provider unit limits and timing/billing rules when submitting professional claims

Procedure, modality codes and billing thresholds

Therapy procedure and modality code groupsCPT

97012-97028	Supervised modality codes (examples listed individually in policy).
97032-97039	Constant attendance modality codes (timed, each 15 minutes for many codes).
97110-97124,97129-97130,97139-97140,97530,97760-97763	Therapeutic procedure codes (timed codes generally per 15 minutes).
97161-97168	Physical and occupational therapy evaluation and re-evaluation codes.
92507-92508,92521-92524	Speech therapy treatment and evaluation codes.

Required modifiersModifier

GP/GO/GN	Plan-of-care modifiers for PT (GP), OT (GO), and speech (GN).
CQ/CO	Therapy assistant modifiers for PTA (CQ) and OTA (CO).

Timed code billing thresholds — minute thresholds and billable ranges

15-minute timed codes — minimum to bill 1 unitA unit is billable when incurred time exceeds the halfway point: 8 minutes; billable range for a single 15-minute unit is 8–22 minutes (and multiples for additional units)

30-minute timed codes — minimum to bill 1 unitA unit is billable when incurred time exceeds the halfway point: 16 minutes; billable range for a single 30-minute unit is 16–45 minutes (and multiples for additional units)

Non-billable durationsTime less than the halfway point is not billable (0–7 minutes for 15-minute increments; 0–15 minutes for 30-minute increments)

Unit counting methodFollow CPT time-based unit counting: a unit is attained when the time midpoint for the code's increment is passed

Modifier 52Modifier 52 (Reduced Services) is not recognized with timed modality or therapeutic services

Provider billing and supervision requirements

Billing Rule

Therapy assistant billing and required modifiers

When a Physical Therapy Assistant (PTA) or Occupational Therapy Assistant (OTA) provides services under the direct supervision of a licensed Physical Therapist or Occupational Therapist, the supervising licensed therapist MUST bill for the services. PTA/OTA services are identified by appending the appropriate therapy assistant modifier to the service line.

CQ – Outpatient physical therapy services furnished in whole or part by a physical therapy assistant
CO – Outpatient occupational therapy services furnished in whole or part by an occupational therapy assistant
Services rendered by the PTA/OTA are billed ONLY by the supervising PT/OT on two lines of a claim when both participate: Line 1: Services by the supervising PT/OT appended with plan of care modifier (GP or GO). Line 2: Services by the PTA/OTA appended with the therapy assistant modifier (CQ or CO) and the plan of care modifier (GP or GO)
If the PTA/OTA rendered the entire service and the supervising PT/OT did not render any part of the service, bill one line for the service rendered by the PTA/OTA appended with the therapy assistant modifier (CQ or CO) and the plan of care modifier (GP or GO)

Modifier and assistant billing definitions

Plan of care modifier — GP/GO/GN meaning and application

Meaning of GP/GO/GNPlan-of-care modifiers indicating services are furnished under a therapy plan: GP = physical therapy; GO = occupational therapy; GN = speech-language pathology

Applicability to 'always therapy' codesThese modifiers must be appended by any provider who renders codes listed as 'always therapy' per CMS Annual Therapy Update and should be appended after any reimbursement modifier

Scope of useDo not apply GP/GO/GN to services other than those defined as therapy services; review the Annual Therapy Code List classifications to determine applicability

Therapy assistant modifiers and billing arrangement — CQ/CO use and claim-line rules

CQ/CO modifier definitionsCQ = outpatient physical therapy services furnished in whole or part by a physical therapy assistant; CO = outpatient occupational therapy services furnished in whole or part by an occupational therapy assistant