CurrentSouth Dakota Department of Social ServicesPolicy N/A

Therapy Services

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South Dakota Medicaid coverage, provider eligibility, ordering, medical necessity, care plans, supervision, billing limits, telemedicine, and prior authorization requirements for occupational, physical, speech, and related therapy services.

Policy Summary

PayerSouth Dakota Department of Social Services

PolicyTherapy Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify recipient eligibility and ensure the provider, written order, care plan, medical necessity, and applicable prior authorization requirements are satisfied before providing therapy.

SourceLink

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CurrentSouth Dakota Department of Social ServicesPolicy N/A

Therapy Services

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Sign up for all South Dakota Department of Social Services policy alerts

Know when South Dakota Department of Social Services releases new policies or updates existing guidance.

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Policy Summary

PayerSouth Dakota Department of Social Services

PolicyTherapy Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify recipient eligibility and ensure the provider, written order, care plan, medical necessity, and applicable prior authorization requirements are satisfied before providing therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/dayCPT 92507 daily limit

30 daysCare-plan certification

90 daysRestorative progress reports

6 yearsRecord retention

6 monthsClaim timely filing

6Non-covered service categories

Policy Scope and Background

South Dakota Medicaid covers outpatient occupational, physical, and speech therapy for the medically necessary treatment of functional impairments or dysfunctions. Covered services must require the expertise of a qualified therapist, be specific and effective under accepted standards of practice, and have a reasonable expectation of significant improvement within a predictable period based on restorative potential. Therapy intended only for maintenance is generally excluded, subject to the documented exception for sustaining function or preventing deterioration.

Coverage Criteria

General coverage principles

Covered services must meet all general coverage requirements.

General coverage requirements

Provider enrollment: The provider is properly enrolled with South Dakota Medicaid.
Medical necessity: The services are medically necessary.
Recipient eligibility: The recipient is eligible for Medicaid coverage.
Prior authorization: The service is prior authorized when applicable under South Dakota Medicaid requirements.
Non-discrimination: The provider complies with applicable non-discrimination requirements.

Medical necessity

Therapy must meet all stated medical-necessity requirements.

Qualified therapist expertise: The complexity and sophistication of the condition require the judgment, knowledge, and skills of a qualified physical, occupational, or speech therapist.
Accepted treatment: The services are specific and effective treatment for the recipient’s condition under accepted standards of medical practice.
Reasonableness and necessity: The services are reasonable and necessary to treat the recipient’s condition.
Expected significant improvement: The recipient is expected to improve significantly within a reasonable and generally predictable period based on the ordering provider’s assessment of restorative potential, after any needed consultation with a qualified PT, OT, or SLP.

Co-treatment

Co-treatment is covered only when all co-treatment conditions are met.

Co-treatment conditions

Recipient benefit: Coordination between the two disciplines benefits the recipient rather than serving merely as a scheduling convenience.
Rationale and goals: The documentation clearly states the rationale for co-treatment and the goals addressed through this method of intervention.
Practitioner documentation: Each practitioner documents the co-treatment session, including the goals addressed and the progress made.
Each practitioner documents the session separately.
Discipline limit: No more than two disciplines provide interventions during one treatment session.

Maintenance therapy

Maintenance-related therapy may be covered only when all exception criteria are met.

Maintenance therapy exception

Covered maintenance purpose
- Therapy is needed to sustain a level of function.
- Without therapy, the recipient’s condition would otherwise deteriorate.
Care-plan documentation: The recipient’s care plan clearly documents the need for the services, including attempts to resolve treatment.
Medical necessity: The services are medically necessary.

CPT 92507 billing rules

CPT 92507 billing is subject to setting and date-of-service rules.

Date-of-service rule: For claims with dates of service on or after July 1, 2025, providers other than school districts billing on a CMS 1500 bill only one unit per member per day.1 unit per member per day
Additional units for the same member on the same day are denied regardless of session length. School districts billing on a CMS 1500 are excepted from this one-unit rule.
Outpatient hospital setting: For outpatient hospitals billing on a UB-04, CPT 92507 is treated as an encounter code for services rendered on the date of service.

Non-covered therapy services

South Dakota Medicaid does not cover any of the following therapy services.

Acupuncture: The requested service is acupuncture.
Independent home exercise: The requested service consists of exercises the recipient can do independently at home.
Massage: The requested service is massage.
Dry needling: The requested service is dry needling.
Equestrian or hippotherapy:

Speech therapy via telemedicine

Speech therapy may be provided via telemedicine when all of the following are met.

Speech therapy telemedicine requirements

Initial in-person contact: An initial in-person contact has been completed.
Ongoing in-person contact: An in-person contact occurs every 90 days thereafter.Every 90 days
Technology requirement: The telemedicine service is provided by means of a real-time interactive telecommunications system.Real-time interactive telecommunications system

Therapy telemedicine requirements

Therapy services may be provided via telemedicine as permitted by the Telemedicine manual.

Therapy telemedicine requirement: Therapy services provided via telemedicine comply with the applicable requirements of the Telemedicine manual.

Refer to the Telemedicine manual for the therapy services permitted via telemedicine.

Services provided by students are not covered. Occupational therapy assistants, physical therapy assistants, and speech-language pathology assistants may perform approved services under the supervision of an enrolled therapist when otherwise permitted, but student-provided services are excluded.

Therapy that is maintenance in nature is not covered. An exception may apply when therapy is needed to sustain a level of function or prevent the recipient's condition from deteriorating. The care plan must clearly document that need, including attempts to resolve treatment; the services must be medically necessary and ordered by a physician, physician assistant, or nurse practitioner.

For dates of service on or after July 1, 2025, providers generally may bill only one unit of CPT 92507 per member per day. Additional units billed for the same member on the same day are denied regardless of session length. School districts billing on a CMS 1500 are excepted from this limitation.

South Dakota Medicaid does not cover acupuncture, exercises a recipient can perform independently at home, massage services, dry needling, equestrian or hippotherapy, or services related to activities for the general good and welfare of patients. The latter includes general exercises intended to promote overall fitness or flexibility and activities intended to provide diversion or general motivation.

Therapy provided by a nursing facility employee or by a therapist under contract with the facility is included in the nursing facility per diem and is not separately billable to South Dakota Medicaid. Therapy provided by a therapist who is neither a facility employee nor under contract with the facility may be separately reimbursable.

Dry needling is not covered by South Dakota Medicaid and is included among the explicitly non-covered therapy services.

Coding, Billing, and Record Requirements

Covered CPT CodesCPTCovered

92507

Speech therapy service billed as a 15-minute time-based code for applicable claims before the rule change; for claims with dates of service on or after July 1, 2025, it is limited to one unit per member per day for all providers except school districts billing on a CMS 1500.

Assistant Service ModifiersModifier

HM	Modifier for services provided by a speech-language pathology assistant (SLPA)
CO	Modifier for services provided by an occupational therapy assistant (OTA)
CQ	Modifier for services provided by a physical therapy assistant (PTA)

Unlisted ProcedureCPT

97799

unlisted physical medicine service

Covered CPT CodesCPTCovered

92508

group speech therapy

CPT 92507 Daily Units

Effective dateClaims with dates of service on or after July 1, 2025

Daily limitOne unit per member per day

ExceptionSchool districts billing on a CMS 1500 are excepted from the one-unit rule

Restorative Therapy Progress Reports

Progress report intervalAt minimum, every 90 days for restorative therapy

Required evaluationProgress toward current goals and professional judgment about continued goals

Provider Requirements and Denial Risks

Prior Authorization

Confirm prior authorization requirements

Obtain prior authorization whenever South Dakota Medicaid requirements make authorization applicable before providing the service.

Prior Authorization

Authorize speech-generating devices first

The recipient’s SLP must obtain South Dakota Medicaid prior authorization before providing an augmentative communication device or modifying a previously authorized device.

Documentation Required

Verify Medicaid eligibility before treatment

Check the recipient’s Medicaid identification card and verify eligibility before providing services. Eligibility may be verified through South Dakota Medicaid’s online portal.

Key Definitions

Co-treatment

ParticipantsPractitioners from different professional disciplines

SettingTreatment is delivered during a single therapy session

Purpose and limitPractitioners address coordinated treatment goals; no more than two disciplines may provide interventions during one session

Maintenance Therapy

PurposeTherapy intended to sustain a level of function or prevent the recipient's condition from deteriorating

Coverage statusMaintenance therapy is not covered unless it meets the stated exception

Exception requirements

Policy Summary

PayerSouth Dakota Department of Social Services

PolicyTherapy Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionVerify recipient eligibility and ensure the provider, written order, care plan, medical necessity, and applicable prior authorization requirements are satisfied before providing therapy.

SourceLink

On This Page

No more than 2 disciplines per session

Qualified ordering provider: The services are ordered by a physician, physician assistant, or nurse practitioner.

The requested service is equestrian therapy or hippotherapy.

General good and welfare activities: The requested service is an activity for general fitness, flexibility, diversion, or general motivation rather than covered therapy treatment.

Additional documentationNecessary goal or treatment modifications and termination of services, if applicable

Medical and Financial Record Retention

Records coveredLegible medical and financial records that justify and disclose the extent of services provided and billed

Retention periodAt least 6 years

Retention begins afterThe last date a claim was paid or denied

Claim Timely Filing

Claim deadlineWithin 6 months following the month the service was provided

Recipient of claimSouth Dakota Medicaid must receive the completed claim form

Possible extensionThe time limit may be waived or extended by South Dakota Medicaid in certain circumstances

Reconsideration Filing

Filing deadlineWithin 3 months of the date a claim was denied

Timely filing alternativeA reconsideration may also be submitted within the applicable timely filing period

Possible exceptionThe time limit may be waived or extended by South Dakota Medicaid in certain circumstances

Group Speech Therapy Units

Claim formatSubmit a claim for each individual Medicaid recipient who received therapy services

Daily limitOne unit per member per day

Additional unitsDenied for the same member on the same day regardless of session length

Speech Therapy Telemedicine Contact

Initial contactAn initial in-person contact must be completed before speech therapy is provided via telemedicine

Ongoing contactAn in-person contact must occur every 90 days thereafter

TechnologyThe service must use a real-time interactive telecommunications system

Documentation Required

Obtain a current written order

Support outpatient therapy with a written prescription from a physician, physician assistant, or nurse practitioner. The order is valid for one year; a new order is required when services continue beyond one year.

For Care Management recipients, obtain the order from the Care Management provider or obtain an additional Care Management referral when another provider orders the service.

Documentation Required

Complete and certify the care plan

Maintain an active written care plan directly and specifically related to the services. The plan must include diagnoses, long-term treatment goals, and the type, amount per day, duration, and frequency per week of therapy.

If an OT, PT, or SLP develops the plan, obtain the ordering provider’s full name and signature within 30 days of initiating therapy.
Recertify after one year and within 30 days of a significant change in the plan or recipient’s condition, documenting continued need and obtaining the recertifying provider’s signature.

Documentation Required

Use a separate plan for each discipline

When a recipient receives multiple therapy disciplines, maintain a separate plan of care for each specialty. Each therapist must independently establish the impairment or dysfunction treated and the associated goals.

Documentation Required

Document medical necessity

Ensure the record and ordering-provider assessment support the complexity of the condition, accepted-standard treatment, reasonableness and necessity, and an expectation of significant improvement within a reasonable and generally predictable period based on restorative potential.

Documentation Required

Document the basis for co-treatment

For co-treatment, each practitioner must document that the method was appropriate, identify the goals addressed, state the progress made, and identify the interventions provided. Documentation must support coordination for the recipient’s benefit rather than scheduling convenience.

Documentation Required

Support an exception for maintenance therapy

For covered maintenance-related therapy, clearly document in the care plan the need to sustain function or prevent deterioration and include attempts to resolve treatment. The services must remain medically necessary and ordered by a physician, physician assistant, or nurse practitioner.

Documentation Required

Provide required assistant supervision

Ensure assistant services are performed by or under the supervision of a PT, OT, or SLP in accordance with applicable licensure provisions.

Documentation Required

Retain records that support billed services

Maintain legible medical and financial records that fully justify and disclose the extent of services provided and billed. Retain the records for at least six years after the last date a claim was paid or denied.

Documentation Required

Complete treatment notes after every visit

Document the recipient’s progress toward therapy goals, retain the ordering provider’s order, and update treatment notes after every visit. Each note must describe what occurred, the time spent performing services, and the therapist’s observations.

Documentation Required

Submit restorative progress reports every 90 days

For restorative therapy, complete a progress report note at least every 90 days. The report must evaluate progress toward current goals, provide professional judgment about continued goals, identify needed goal or treatment modifications, and document termination when necessary.

Documentation Required

Record start and stop times

Maintain service start and stop times in the medical record for time-based therapy codes.

Billing Rule

Bill assistant services under the supervisor

Bill assistant services through the supervising therapist using the required modifier and list the supervising therapist’s NPI in box 24J or the 837P equivalent. South Dakota Medicaid recommends that the supervising therapist review and sign documentation for submitted claims.

Use HM for an SLPA, CO for an OTA, and CQ for a PTA.

Documentation Required

Describe CPT 97799 services

When billing CPT 97799, submit documentation describing the unlisted physical medicine service provided.

Billing Rule

Enroll and list home health therapy providers

Eligible providers furnishing therapy through a Medicare-certified home health agency must enroll with South Dakota Medicaid. List all eligible providers who provide services on the claim form.

Billing Rule

Include the ORP NPI

For OT, PT, and SLP therapy claims for recipients without a Care Management provider, include the ordering, referring, and prescribing provider NPI on the claim.

Denial Risk

Confirm provider and practitioner eligibility

Ensure all eligible servicing and billing providers’ NPIs are enrolled with South Dakota Medicaid. Assistants may not enroll independently and must work under an enrolled supervising therapist; services provided by students are not covered.

Denial Risk

Meet all core coverage requirements

Before billing, confirm provider enrollment, recipient eligibility, medical necessity, any applicable prior authorization, a written order, and an active compliant care plan. Missing diagnoses, goals, treatment parameters, certification, recertification, or evidence of expected significant improvement may result in denial.

Denial Risk

Avoid unsupported maintenance therapy claims

Maintenance therapy is not covered unless the care plan clearly documents the need to sustain function or prevent deterioration and includes attempts to resolve treatment. The services must also be medically necessary and ordered by a physician, physician assistant, or nurse practitioner.

Denial Risk

Limit CPT 92507 to one daily unit

For dates of service on or after July 1, 2025, bill no more than one unit of CPT 92507 per member per day, except for school districts billing on a CMS 1500. Additional units are denied regardless of session length.

Denial Risk

Do not provide unauthorized speech devices

Do not provide an augmentative communication device or modify a previously authorized device until the recipient’s SLP obtains South Dakota Medicaid prior authorization.

Denial Risk

Do not bill non-covered therapy services

Claims may be denied for acupuncture, exercises a recipient can independently perform at home, massage, dry needling, equestrian or hippotherapy, or activities for general fitness, flexibility, diversion, or general motivation.

Denial Risk

Do not separately bill bundled facility therapy

Therapy provided by a nursing facility employee or by a therapist under contract with the facility is included in the nursing facility per diem and is not separately billable to South Dakota Medicaid.

Billing Rule

Keep co-treatment billing within actual time

When two or more disciplines co-treat during the same block of time, split the time between disciplines for billing. Total billed time cannot exceed the actual time spent with the patient.

Alternatively, the full time may be billed by only one discipline, but not by both.

Denial Risk

File claims and reconsiderations on time

Submit the completed claim within six months following the month the service was provided. Reconsiderations must be received within the timely filing period or within three months of the claim denial, subject to possible waiver or extension by South Dakota Medicaid.

Denial Risk

Prevent CPT 97799 documentation denials

Submit documentation describing the service provided with every CPT 97799 claim. Claims without documentation of the service provided will be denied.

Denial Risk

Limit group speech therapy billing

For group speech therapy CPT 92508, submit one claim for each Medicaid recipient and bill only one unit per member per day. Additional units for the same member on the same day are denied regardless of session length.

Denial Risk

Avoid overlapping co-treatment billing

When disciplines co-treat during the same block of time, do not bill the full same time separately for each discipline. The total billed time must not exceed the actual time spent with the patient.

Denial Risk

Do not bill under an ineligible respiratory care practitioner

Respiratory care practitioners are not eligible to enroll with South Dakota Medicaid and therefore cannot serve as eligible enrolled billing providers under this policy.

The care plan must document the need, including attempts to resolve treatment; services must be medically necessary and ordered by a physician, physician assistant, or nurse practitioner

Written Care Plan

Required clinical contentDiagnoses and long-term treatment goals

Treatment parametersType of therapy, amount per day, duration, and frequency per week

CertificationThe ordering provider must certify the plan within 30 days of initiating therapy when the plan is developed by an OT, PT, or SLP; recertification is required after one year if services continue

Telemedicine

DefinitionA real-time interactive telecommunications system used to deliver telemedicine services

Speech therapy prerequisiteAn initial in-person contact must be completed before speech therapy is provided via telemedicine

Ongoing contactAn in-person contact must occur every 90 days thereafter for speech therapy via telemedicine

ORP NPI

MeaningOrdering, referring, and prescribing provider national provider identifier

Claims requirementThe ORP NPI is required on applicable therapy claims

Applicable servicesOccupational therapy, physical therapy, and speech-language pathology therapy claims for recipients without a Care Management provider