CurrentUnitedHealthcarePolicy 2025R0098A

CMS 1500: PT, OT and Evaluation & Management Reimbursement Policy, Professional

Defines UnitedHealthcare reimbursement rules for services billed on the CMS‑1500 (professional) form for physical therapy, occupational therapy, evaluations, and related E/M codes and therapy modifiers for Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500: PT, OT and Evaluation & Management Reimbursement Policy, Professional

Policy CodePolicy 2025R0098A

Change TypeAdministrative/template consolidation

Effective Date

Next Review Date

Key ActionSubmit accurate claims using codes that correctly describe services; UnitedHealthcare may exercise discretion in application.

SourceLink

POLICY UPDATE CHANGES

Policy content was transferred to a shared policy template that applies to both UnitedHealthcare Commercial and Individual Exchange benefit plans.

97161-97168PT/OT eval codes reimbursed

99091, 99202-99499, G2252E/M and related codes not reimbursed

GO/GPTherapy discipline modifiers required

CO/CQAssistant‑delivered service modifiers

CMS‑1500

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Coverage Criteria and Billing Rules

Therapy billing and modifier criteria

Covered when the following reimbursement and modifier rules are met for services billed on the CMS‑1500 (professional) claim form:

ALL of the following

This policy applies to UnitedHealthcare Commercial and Individual Exchange benefit plans and to network and non‑network physicians and other qualified health care professionals.
Providers are responsible for submission of accurate claims using codes that correctly describe services; other UnitedHealthcare reimbursement policies may also apply and UnitedHealthcare may exercise discretion in application.

Physical and Occupational Therapists may be reimbursed for CPT codes 97161-97164 and 97165-97168 when appropriately billed by a PT or OT.

Physical and Occupational Therapy Assistants (PTAs/OTAs) will not be reimbursed for CPT codes 97161-97164 or 97165-97168.

Physical and Occupational Therapists and PTAs/OTAs will not be reimbursed for CPT evaluation and management codes 99091, 99202-99499 or HCPCS G2252, consistent with CMS coding guidelines.

HCPCS modifiers GO and GP must be reported with codes designated by CMS as 'always therapy services' to identify the discipline of the plan of care (effective July 1, 2020).

HCPCS modifiers CQ and CO are required for services furnished In Whole or In Part by a PTA or OTA (effective January 1, 2020). These modifiers must appear on the same claim line alongside the applicable GP or GO modifier: CQ paired with GP; CO paired with GO.

CQ and CO modifiers do not apply to assistant‑delivered services that are billed 'incident to' physicians or nonphysician practitioners.

Relevant Codes and Modifiers

PTA/OTA Share Threshold and Modifier Use

PT/OT evaluation codes reimbursedCPT 97161-97164 and 97165-97168 are reimbursed when performed by licensed Physical or Occupational Therapists. Physical and Occupational Therapy Assistants (PTA/OTA) will not be reimbursed for CPT codes 97161-97164 or 97165-97168.

Therapy discipline modifiersUse HCPCS modifier GP for Physical Therapy and GO for Occupational Therapy on services CMS designates as 'always therapy services'.

PTA/OTA modifiers and pairingUse CQ (paired with GP) for PTA involvement and CO (paired with GO) for OTA involvement when services are furnished In Whole or In Part by a PTA/OTA. These modifiers should be reported on the service line alongside the respective GP or GO modifier.

PTA/OTA threshold definition'In Part' is when PTA/OTA minutes exceed 10% of the total minutes for that service; 'In Whole' is when all minutes are furnished by the PTA/OTA.

ExclusionsCQ and CO do not apply to services furnished 'incident to' physician or nonphysician practitioner services. Additionally, PT/OT providers should not report evaluation and management CPT codes 99091, 99202-99499, or HCPCS G2252 for reimbursement per CMS coding guidelines.

Provider Responsibilities and Claims Submission

Documentation Required

Submit accurate claims and expect policy discretion

You are responsible for submission of accurate claims that use the code or codes that correctly describe the health care services provided. UnitedHealthcare reimbursement policies may use CPT, CMS or other coding guidelines; the policy may be modified and UnitedHealthcare may exercise reasonable discretion in interpreting and applying it to a particular case.

Terms and Role Definitions

Physical Therapist

DefinitionPhysical Therapist: an individual who is licensed, if applicable, as a Physical Therapist by the State in which he or she is practicing.

ScopePTs may bill and be reimbursed for applicable PT evaluation CPT codes when appropriately billed by a licensed PT.

Licensing noteLicensure applies if required by the State of practice.

Occupational Therapist

DefinitionOccupational Therapist: an individual who is licensed, if applicable, as an Occupational Therapist by the State in which he or she is practicing.

ScopeOTs may bill and be reimbursed for applicable OT evaluation CPT codes when appropriately billed by a licensed OT.

Policy Summary

PayerUnitedHealthcare

PolicyCMS 1500: PT, OT and Evaluation & Management Reimbursement Policy, Professional

Policy CodePolicy 2025R0098A

Change TypeAdministrative/template consolidation

Effective Date

Next Review Date

Key ActionSubmit accurate claims using codes that correctly describe services; UnitedHealthcare may exercise discretion in application.

SourceLink

On This Page

Licensing noteLicensure applies if required by the State of practice.

Physical Therapy Assistant

DefinitionPhysical Therapy Assistant (PTA): an individual who is licensed as a PTA, unless licensure does not apply, or is registered or certified, if applicable, as a PTA by the State in which he or she is practicing.

Licensing/Registration/CredentialingPTAs must hold the applicable state license, registration, or certification when required by the State of practice.

Billing implicationPTA‑delivered minutes count toward the assistant share threshold used to determine CQ/CO modifier reporting.

Occupational Therapy Assistant

DefinitionOccupational Therapy Assistant (OTA): an individual who is licensed as an OTA, unless licensure does not apply, or is registered or certified, if applicable, as an OTA by the State in which he or she is practicing.

Licensing/Registration/CredentialingOTAs must hold the applicable state license, registration, or certification when required by the State of practice.

Billing implicationOTA‑delivered minutes count toward the assistant share threshold used to determine CQ/CO modifier reporting.

In Whole

DefinitionIn Whole: all the minutes of a service exclusive of the occupational therapist/physical therapist (as applicable).

ImplicationIndicates the assistant furnished the entirety of the assistant portion of the service for that line item.

Relation to modifiersIf a service is furnished 'In Whole' by a PTA/OTA, CQ or CO modifiers are required as applicable.

In Part

DefinitionIn Part: a portion of a service separately from the part furnished by the occupational/physical therapist such that the minutes for that portion of a service furnished by the OTA or PTA exceed 10 percent of the total minutes for that service.

ThresholdAssistant‑furnished portion exceeds 10% of total service minutes to qualify as 'In Part' for modifier reporting.

Relation to modifiersWhen 'In Part' meets the >10% threshold, report CQ (with GP) or CO (with GO) on the same claim line.