CurrentUnitedHealthcarePolicy 2025R0098A

PT, OT and Evaluation & Management Policy, Professional

Defines UnitedHealthcare reimbursement rules for physical and occupational therapy evaluations, evaluation and management services, and required HCPCS therapy modifiers for claims billed on the CMS-1500 form for Commercial and Individual Exchange plans.

Policy Summary

PayerUnitedHealthcare

PolicyPT, OT and Evaluation & Management Policy, Professional

Policy CodePolicy 2025R0098A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit claims using CMS-1500 or electronic equivalent and ensure accurate coding and modifier reporting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

97161-97168PT/OT evaluation CPTs referenced

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

GO, GP, CO, CQTherapy HCPCS modifiers

Commercial & ExchangeApplicable benefit plans

Therapy Reimbursement Criteria

Reimbursement rules and requirements for PT/OT services billed on CMS-1500:

PTs and OTs will be reimbursed for appropriate use of CPT codes 97161-97164 and 97165-97168 when billed by licensed therapists.

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

UnitedHealthcare will not reimburse Physical and Occupational Therapists or PT/OTAs for evaluation and management CPT codes 99091, 99202-99499 or HCPCS code G2252, consistent with CMS coding guidelines.

HCPCS modifiers GO and GP must be reported for codes designated by CMS as 'always therapy services' to indicate the discipline of the plan of care.

For services furnished in whole or in part by a PTA or OTA, use modifier CQ paired with GP for PTA involvement and modifier CO paired with GO for OTA involvement; these modifiers do not apply to services furnished 'incident to' physicians or nonphysician practitioners.

Policy Summary

PayerUnitedHealthcare

PolicyPT, OT and Evaluation & Management Policy, Professional

Policy CodePolicy 2025R0098A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit claims using CMS-1500 or electronic equivalent and ensure accurate coding and modifier reporting.

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 Involvement

Therapy evaluation and non-reimbursable E/M codesCPTCovered

97161-97164	PT/OT evaluation CPT codes (low to high complexity)
97165-97168	PT/OT evaluation CPT codes (low to high complexity)
99091, 99202-99499	Evaluation and management codes not reimbursed for PT/OT or PT/OTA
G2252	HCPCS code not reimbursed for PT/OT or PT/OTA

HCPCS modifiers for therapy servicesModifier

GO	Modifier indicating occupational therapy
GP	Modifier indicating physical therapy
CO	Modifier indicating service furnished in part or whole by OTA (pairs with GO)
CQ	Modifier indicating service furnished in part or whole by PTA (pairs with GP)

OTA/PTA involvement threshold — 'In Part' criteria

ThresholdOTA/PTA minutes exceed 10% of total service minutes to be considered 'in part'

ApplicationApplies when determining whether a service was furnished 'in part' by an OTA or PTA for modifier reporting (CO pairs with GO; CQ pairs with GP)

CalculationCompare total minutes of the service to minutes performed by OTA or PTA; if OTA/PTA minutes >10% of total, classify as 'in part'

Reimbursement implicationUse OTA/PTA 'in part' designation when applying CQ (PTA) or CO (OTA) modifiers on CMS-1500 claims

Claims Submission and Modifier Reporting

Billing Rule

Claims Submission Requirement

Submit claims using the CMS-1500 (1500 Health Insurance Claim Form) or its electronic equivalent. Ensure accurate coding and submission for all products and all network and non‑network physicians and other qualified health care professionals.

Use CMS-1500 or electronic equivalent for claim submission.
Applies to all products, network and non-network providers.

Billing Rule

Modifier Reporting Requirement

Report the HCPCS therapy discipline modifiers GO and GP on service lines CMS designates as "always therapy services" to identify the discipline of the plan of care. For services furnished in whole or in part by Physical Therapy Assistants (PTAs) or Occupational Therapy Assistants (OTAs), report the CQ or CO modifiers on the same claim line alongside the appropriate therapy modifier: CQ with GP and CO with GO. CQ and CO are not used for PTA/OTA services furnished "incident to" physician or nonphysician practitioner services.

Effective for claims with dates of service on or after July 1, 2020: report GO and GP for CMS-designated "always therapy services."
Effective for claims with dates of service on or after January 1, 2020: report CQ for services furnished in whole or in part by a PTA paired with GP.
Effective for claims with dates of service on or after January 1, 2020: report CO for services furnished in whole or in part by an OTA paired with GO.
Do not report CQ or CO for PTA/OTA services billed "incident to" physician or nonphysician practitioner.

Roles and Terms

Physical Therapist — definition

TermPhysical Therapist

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

RelevancePTs are eligible to bill CPT codes 97161-97168 for evaluations when appropriately licensed

Occupational Therapist — definition

TermOccupational Therapist

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

RelevanceOTs are eligible to bill appropriate occupational therapy evaluation codes when licensed

Physical Therapy Assistant — definition

TermPhysical Therapy Assistant (PTA)

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

RolePTAs may furnish portions of therapy services; PTA minutes are counted to determine 'in part' status but PTAs are not reimbursed for evaluation CPT codes.

Occupational Therapy Assistant — definition

TermOccupational Therapy Assistant (OTA)

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

RoleOTAs may furnish portions of therapy services; OTA minutes are counted to determine 'in part' status and affect modifier use.

In Whole — definition

TermIn Whole

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

ImplicationUse 'In Whole' when the assistant does not furnish any portion of the billed service minutes separate from the therapist.

In Part — definition

TermIn Part

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.

UseClassify services as 'In Part' when OTA/PTA minutes >10% of total; this affects use of CO/CQ modifiers on claims.