CurrentUnitedHealthcarePolicy N/A

Physical medicine and rehabilitation timed therapy reimbursement

Governs reimbursement for physical medicine and rehabilitation therapy CPT/HCPCS codes that include a time element (timed codes) for UnitedHealthcare Community Plan Medicaid products; affects physicians and other qualified health care professionals billing on CMS-1500/UB04 as specified.

Policy Summary

PayerUnitedHealthcare

PolicyPhysical medicine and rehabilitation timed therapy reimbursement

Policy CodePolicy N/A

Change TypeNon-material state exception updates and implementation note

Effective DateN/A

Next Review DateMar 16, 2025

Key ActionSubmit a Reconsideration Request for claims that exceed four timed codes per date of service to request additional reimbursement.

SourceLink

POLICY UPDATE CHANGES

State Exceptions Section: Updated CO

State Exceptions Section: Updated KS

Policy implemented by UnitedHealthcare Community & State

4maximum timed codes reimbursed per date of service (same-specialty provider)

8 minminimum time to bill one 15-minute unit

8AZ Medicaid max units (state exception)

6WI Medicaid max units (state exception)

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Timed codes coverage criteria and state exceptions

Reimbursement is provided for timed physical medicine and rehabilitation therapy CPT/HCPCS codes when coded per CMS/CPT guidelines, subject to per‑day timed code limits and state exceptions.

Services are billed in accordance with CMS and CPT/HCPCS coding guidelines; at least 8 minutes of therapy must be performed to bill one 15‑minute unit.

From policy overview and minimum time requirement.

Reimbursement is limited to a maximum of four timed codes (equivalent to one hour of therapy) per date of service when provided by the Same Specialty Physician or Other Qualified Health Care Professional.

Standard per‑date limit to reflect usual one‑hour session.

Exceptions for multi‑specialty groups: When timed services are provided by professionals of different specialties within a multi‑specialty group reporting under the same FEIN, allow up to four timed codes per specialty provider type per date of service.

HCPCS modifiers GN, GO, GP may be reported to distinguish specialists.

Exceeding four timed codes: Claims exceeding four timed codes per date of service may be considered for additional reimbursement upon Reconsideration Request.

Claim reconsideration may not apply in some states.

State exceptions (select applicable state rule)

Arizona: maximum 8 units per day for Medicaid.
Colorado: daily limit of 5 units PT and 5 units OT (rehabilitative or habilitative); some procedure‑specific daily limits may apply.
Indiana: Indiana is exempt from this policy per state regulation.
Kansas: Kansas is exempt from this policy per state requirements.
Michigan: Medicaid is exempt from this policy per state requirements.
Missouri: maximum of 5 units allowed for Medicaid.

Services provided in the home or in a comprehensive inpatient or outpatient rehabilitation facility are excluded from this policy.

Setting‑based exclusions.

CPT/HCPCS Timed Therapy Codes and Billing Rules

Examples and crosswalks of timed therapy CPT/HCPCS codesmixed

97110	Therapeutic exercises
97535	Self-care/home management training
G0237	Timed HCPCS cross-reference
97116	(see crosswalks in Q&A)
97113	(see crosswalks in Q&A)
97533	(see crosswalks in Q&A)
97763	(see crosswalks in Q&A)
97761	(see crosswalks in Q&A)
97034	(see crosswalks in Q&A)
97033	(see crosswalks in Q&A)

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Minimum unit time

Minimum time to bill one 15-minute unitAt least 8 minutes of therapy services must be performed to meet the minimum time qualification to bill one 15‑minute unit.

Source guidanceRequirement aligned with Centers for Medicare and Medicaid Services (CMS) and CPT/HCPCS coding guidance as stated in policy overview.

ApplicabilityApplies to Physical Medicine and Rehabilitation timed CPT/HCPCS codes reported to UnitedHealthcare Community Plan Medicaid.

Maximum timed codes reimbursed per date of service (same-specialty provider)

Maximum timed codes per date of service (same-specialty provider)4 timed codes per date of service (equivalent to one hour of therapy).

Multi-specialty group ruleWhen different specialties within the same FEIN report (e.g., PT, OT), reimbursement is allowed for up to four timed codes for each specialty provider type per date of service; use HCPCS modifiers GN/GO/GP to distinguish specialists.

Exceeding four codesClaims exceeding four timed codes may be considered for additional reimbursement upon Reconsideration Request; reconsideration may not apply in some states.

Provider Actions, Reconsideration, and Billing Guidance

Prior Authorization

Submit a Reconsideration Request for claims exceeding four timed codes

Claims that exceed four timed physical medicine and rehabilitation codes on the same date of service may be considered for additional reimbursement if a Reconsideration Request is submitted; claim reconsideration may not be available in some states.

Reconsideration applies when services are correctly billed per CMS and CPT/HCPCS Coding Guidelines but exceed four timed codes per date of service.
Reconsideration availability is subject to state law and may not apply in some states.

Key Definitions

Same Specialty Physician or Other Qualified Health Care Professional

DefinitionSame Specialty Physician or Other Qualified Health Care Professional — the physician or other qualified health care professional of the same specialty providing timed physical medicine and rehabilitation therapy services to be reimbursed under this policy.

Billing forms and settingsApplies to services reported using the CMS-1500 (or electronic equivalent) for UnitedHealthcare Community Plan Medicaid; does not apply to services provided in the home or in comprehensive inpatient/outpatient rehabilitation facilities (Place of Service 12, 61, 62).

Provider network scopePolicy applies to all network and non-network physicians and other qualified health care professionals, including non-network authorized and percent-of-charge contract providers, when billing applicable timed codes.