CurrentUnitedHealthcarePolicy 2024R0098A

Reimbursement Policy CMS-1500 — Therapy services and modifier requirements

Defines which CPT/HCPCS codes and therapy modifiers are reimbursable for physical and occupational therapy services billed on CMS-1500 forms and describes provider/assistant payment and modifier requirements. Affects providers submitting claims to UnitedHealthcare Community Plan.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy CMS-1500 — Therapy services and modifier requirements

Policy CodePolicy 2024R0098A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims using codes that correctly describe services and report required therapy modifiers (GO/GP and CQ/CO) when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97161-97168Therapy evaluation codes addressed

GO/GPAlways-therapy discipline modifiers

CQ/COAssistant-provided service modifiers

PTA/OTA excludedAssistants excluded from eval codes

TexasState exception

Therapy Reimbursement Criteria

Therapy reimbursement criteria

Reimbursement position and reporting rules for therapy services, evaluation/E&M codes, and HCPCS therapy/assistant modifiers.

ALL of the following

ALL of the following
- Physical and Occupational Therapists will be reimbursed for appropriate use of CPT codes 97161-97164 or 97165-97168.
- Physical and Occupational Therapy Assistants will not be reimbursed for CPT codes 97161-97164 or 97165-97168.
ALL of the following
- UnitedHealthcare Community Plan will not reimburse PTs, PTAs, OTs, or OTAs for CPT 99091, 99202-99499 or HCPCS G2252, consistent with CMS coding guidelines.

Policy Summary

PayerUnitedHealthcare

PolicyReimbursement Policy CMS-1500 — Therapy services and modifier requirements

Policy CodePolicy 2024R0098A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionSubmit accurate claims using codes that correctly describe services and report required therapy modifiers (GO/GP and CQ/CO) when applicable.

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.

Codes, Modifiers, and Assistant Rules

Therapy evaluation and E/M codingCPTCovered

97161-97164	Physical/Occupational therapy evaluation codes (low to high complexity)
97165-97168	Physical/Occupational therapy evaluation codes (low to high complexity)
99091, 99202-99499, G2252	Evaluation and management codes not reimbursed for PTs/PTAs/OTs/OTAs

HCPCS modifiers — discipline and assistant modifiersModifier

GO	Physical therapy modifier
GP	Occupational therapy modifier
CQ	Service furnished in whole or in part by an occupational therapy assistant (paired with GP)
CO	Service furnished in whole or in part by a physical therapy assistant (paired with GO)

PTA/OTA 'In Part' definition — minutes threshold rule

PTA/OTA 'In Part' minutes thresholdPortion of a service is considered 'in part' when the minutes furnished by the OTA or PTA exceed 10% of the total minutes for that service.

ApplicationUsed to determine when CQ (OTA) or CO (PTA) modifiers must be reported on the claim line for services furnished in part by an assistant.

Exclusion for 'incident to'Modifiers CQ/CO are not applied to 'incident to' services (per modifier reporting rules).

Claims Submission and Modifier Reporting

Billing Rule

Claims submission responsibility and coding guidance

You are responsible for submission of accurate claims. Submit claims that correctly describe the health care services provided and follow CPT, CMS and other coding guidelines, applicable UnitedHealthcare reimbursement policies, and contractual requirements. Failure to report appropriate codes and modifiers may result in claim denials or incorrect reimbursement.

Submit accurate claims using the code or codes that correctly describe the services provided.
Follow CPT, CMS and other coding guidelines and UnitedHealthcare Community Plan reimbursement policies.
Claims billed on CMS 1500 and, when specified, UB04 forms must follow this policy and any applicable contract or regulatory requirements.

Billing Rule

Therapy discipline modifier requirement

Report the HCPCS therapy discipline modifiers as required by CMS and UnitedHealthcare Community Plan: • Use modifier GP to indicate services provided under an occupational therapy plan of care. • Use modifier GO to indicate services provided under a physical therapy plan of care. These modifiers are required on claim lines for codes designated by CMS as 'always therapy services' to distinguish the discipline of the plan of care under which the service is delivered.

Effective for dates of service on or after May 1, 2020, report HCPCS modifiers GO (physical therapy) and GP (occupational therapy) with codes designated by CMS as 'always therapy services'.
Refer to the Procedure to Modifier Policy for additional information and system-specific reporting guidance.

Billing Rule

PTA/OTA modifier reporting

Report PTA/OTA modifiers CQ and CO when services are furnished in whole or in part by a Physical Therapy Assistant or Occupational Therapy Assistant. Use these modifiers on the same claim line as the corresponding therapy discipline modifier: CQ must be paired with GP; CO must be paired with GO. Do not apply CQ/CO to PTA/OTA services that are provided 'incident to' physicians or nonphysician practitioners.

Effective for dates of service on or after January 1, 2020, HCPCS modifiers CQ and CO are required when services are furnished in whole or in part by PTAs or OTAs.
Modifier pairing: CQ + GP (occupational therapy); CO + GO (physical therapy).
Do not use CQ/CO for PTA/OTA services billed as 'incident to' a physician or nonphysician practitioner.
Place CQ/CO on the service claim line alongside the GP or GO modifier.

Key Roles and Terms

Physical Therapist

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

RoleProvides physical therapy services and may supervise assistants according to state law and scope of practice.

Reimbursement notePTs are reimbursed for appropriate use of CPT evaluation and therapy codes; assistants are not reimbursed for evaluation codes.

Occupational Therapist

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

RoleProvides occupational therapy services and may supervise occupational therapy assistants according to state law and scope of practice.

Reimbursement noteOTs are reimbursed for appropriate use of CPT evaluation and therapy codes; OTAs are subject to assistant modifier and reimbursement rules.

Physical Therapy Assistant (PTA)

DefinitionAn individual who is licensed as a Physical Therapy Assistant (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.

RoleFurnishes portions of physical therapy services under the direction/supervision of a Physical Therapist as allowed by state law.

Modifier reportingWhen PTA minutes exceed 10% of total service minutes, CO modifier must be reported on the claim line (except where state exceptions apply).

Occupational Therapy Assistant (OTA)

DefinitionAn individual who is licensed as an Occupational Therapy Assistant (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.

RoleFurnishes portions of occupational therapy services under the direction/supervision of an Occupational Therapist as allowed by state law.

Modifier reportingWhen OTA minutes exceed 10% of total service minutes, CQ modifier must be reported on the claim line (except where state exceptions apply).

In Whole

DefinitionAll the minutes of a service exclusive of the occupational therapist/physical therapist (as applicable).

ImplicationIndicates services furnished entirely by an assistant rather than by the therapist; triggers modifier reporting when applicable.

Use in claimsApplied to determine when CO/CQ modifiers represent services furnished 'in whole' by an assistant for a given service line.

In Part — assistant-provided portion threshold

DefinitionA 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.

Threshold value10% of the total service minutes is the cutoff to classify an assistant-provided portion as 'in part'.

Claims effectWhen met, report CQ (OTA) or CO (PTA) modifiers on the claim line for the service (subject to state exceptions).