CurrentUnitedHealthcarePolicy CSNC.MP.164.04

Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for North Carolina Only)

Defines UnitedHealthcare's coverage guidance for occupational, physical, and speech habilitation and rehabilitation therapy services for members in North Carolina; excludes cognitive therapy which is covered under a separate policy.

Policy Summary

PayerUnitedHealthcare

PolicyHabilitation and Rehabilitation Therapy (Occupational, Physical, and Speech) (for North Carolina Only)

Policy CodePolicy CSNC.MP.164.04

Change TypeCodes removed and state fee-schedule notation added

Effective DateNov 1, 2025

Next Review Date

Key ActionVerify the member's federal, state, or contractual benefit requirements and any plan-specific authorization rules prior to billing.

SourceLink

POLICY UPDATE CHANGES

Removed CPT/HCPCS codes 97533, 97537, G0152, and S9476 from the Applicable Codes list.

Added notation that CPT code 97033 is not on the State of North Carolina Medicaid Fee Schedule and therefore may not be covered by the State of North Carolina Medicaid Program.

Removed the Description of Services section from the Supporting Information.

Archived previous policy version CSNC.MP.164.03.

~70CPT/HCPCS codes listed

NC-onlyPolicy application jurisdiction

Excludes cognitive therapyScope exclusion

References NC Medicaid 10A

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Coverage Criteria — Habilitation & Rehabilitation Therapies

Coverage dependent on NC Medicaid Clinical Criteria

Covered when medical necessity is met per referenced NC Medicaid clinical criteria.

General coverage: Services (occupational therapy, physical therapy, and speech therapy) for North Carolina members are covered when they meet medical necessity criteria as defined by the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Outpatient Specialized Therapies (10A).

This policy delegates the detailed clinical criteria and documentation requirements to NC Medicaid Clinical Coverage Policy 10A; providers must consult that document for specific eligibility and documentation standards.

This policy does not apply to cognitive therapy. Outpatient cognitive therapy is governed by the separate Medical Policy titled Cognitive Rehabilitation; providers should refer to that policy for coverage and clinical criteria for cognitive therapy services.

Several codes in the Applicable Codes list are marked with an asterisk; these codes are not on the State of North Carolina Medicaid Fee Schedule and may not be covered by NC Medicaid (for example, 97033 is noted in the brief as not on the NC fee schedule). Providers should verify fee-schedule applicability and potential coverage limitations before billing.

Applicable Codes and Billing Notes

Speech therapy CPT codesCPTCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
92508	Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals.
92521	Evaluation of speech fluency (e.g., stuttering, cluttering).
92522	Evaluation of speech sound production (e.g., articulation, phonological process, apraxia, dysarthria).
92523	Evaluation of speech sound production with evaluation of language comprehension and expression.
92524	Behavioral and qualitative analysis of voice and resonance.
92526	Treatment of swallowing dysfunction and/or oral function for feeding.

Modalities and related CPT codesCPTCovered

92609	Therapeutic services for the use of speech-generating device, including programming and modification.
92610	Evaluation of oral and pharyngeal swallowing function.
96105	Assessment of aphasia with interpretation and report, per hour.
97012	Application of a modality to 1 or more areas; traction, mechanical.
97014	Application of a modality to 1 or more areas; electrical stimulation (unattended).
97016	Application of a modality to 1 or more areas; vasopneumatic devices.
97018	Paraffin bath.
97022	Whirlpool.
97024	Diathermy (e.g., microwave).
97026	Infrared.

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Therapeutic procedures and evaluation CPT codesCPTCovered

97110	Therapeutic exercises to develop strength and endurance, range of motion and flexibility.
97112	Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception.
97113	Aquatic therapy with therapeutic exercises.
97116	Gait training (includes stair climbing).
97139	Unlisted therapeutic procedure (specify).
97140	Manual therapy techniques, each 15 minutes.
97150	Therapeutic procedure(s), group (2 or more individuals).
97161	Physical therapy evaluation: low complexity.
97162	Physical therapy evaluation: moderate complexity.
97163	Physical therapy evaluation: high complexity.

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Therapeutic activities, assistive technology, orthotics/prostheticsCPTCovered

97530	Therapeutic activities, direct (one-on-one) patient contact, each 15 minutes.
97535	Self-care/home management training, direct one-on-one contact, each 15 minutes.
97542	Wheelchair management, each 15 minutes.
97750	Physical performance test or measurement with written report, each 15 minutes.
97755	Assistive technology assessment with written report, each 15 minutes.
97760	Orthotic(s) management and training, initial orthotic(s) encounter, each 15 minutes.
97761	Prosthetic(s) training, initial prosthetic(s) encounter, each 15 minutes.
97763	Orthotic/prosthetic management and/or training, subsequent encounter, each 15 minutes.
97799	Unlisted physical medicine/rehabilitation service or procedure.

HCPCS/G-codes and State-specific codes (some not on NC Fee Schedule)HCPCS

G0281	Electrical stimulation (unattended) for chronic Stage III/IV pressure ulcers and certain non-healing wounds as part of a therapy plan of care.
G0283	Electrical stimulation (unattended) for indications other than wound care, as part of a therapy plan of care.
S8948	Application of a modality requiring constant provider attendance; low-level laser; each 15 minutes.
S8990	Physical or manipulative therapy performed for maintenance rather than restoration.
S9129	Occupational therapy, in the home, per diem.
S9131	Physical therapy; in the home, per diem.
S9152	Speech therapy, re-evaluation.

Wound care electrical stimulation timeframe — G0281

G0281 eligibility timeframeNot demonstrating measurable signs of healing after 30 days of conventional care

Applicable wound types (per G0281 description)Chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers

Service contextElectrical stimulation (unattended) delivered as part of a therapy plan of care

Provider Responsibilities & Authorization

Prior Authorization

Prior authorization — verify per contract

Prior authorization requirements vary by contract and by member type. Verify prior authorization, coverage rules, and any authorization exceptions per the member's federal, state, and contractual benefit requirements before scheduling services or billing. This policy is informational; always follow the applicable benefit plan terms.

Check member-specific federal, state, and contractual benefit requirements prior to billing
Confirm any required prior authorization with UnitedHealthcare per the provider contract

Documentation Required

Provider action — reference federal, state, or contractual requirements

Providers must reference federal, state, or contractual benefit plan requirements when determining coverage and reimbursement. In the event of a conflict between this Medical Policy and applicable federal, state, or contractual requirements, the federal, state, or contractual requirements govern. This policy is provided for informational purposes and does not replace benefit verification.

Background

This policy addresses habilitation and rehabilitation therapy services provided by occupational therapists, physical therapists, and speech-language pathologists in outpatient settings for North Carolina members. It covers evaluation and treatment services delivered by OT, PT, and speech professionals and delegates specific medical necessity determinations to the North Carolina Medicaid Clinical Coverage Policy, Outpatient Specialized Therapies (10A). The policy explicitly excludes cognitive therapy and directs providers to the Cognitive Rehabilitation policy for those services.

Definitions and Referenced Policies

Cognitive therapy — policy scope

Policy exclusionThis Medical Policy does not apply to cognitive therapy

Alternate policyOutpatient cognitive therapy is governed by the Medical Policy titled Cognitive Rehabilitation

Provider actionRefer to the Cognitive Rehabilitation policy for coverage and medical necessity criteria for cognitive therapy services

NC Medicaid Clinical Coverage Policy 10A (reference)

Referenced clinical criteriaNorth Carolina Medicaid, Division of Health Benefits, Clinical Coverage Policies, Outpatient Specialized Therapies (10A)

Purpose of referenceSource for medical necessity clinical coverage criteria for outpatient specialized therapies in North Carolina