CHAPTER 515: Occupational Therapy and Physical Therapy (Policy 515.1)
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Defines Medicaid coverage, limitations, provider qualifications, prior authorization, and settings for occupational and physical therapy services under West Virginia Medicaid.
No material clinical or coverage changes in this revision.
Coverage criteria and exclusions
General coverage criteria
Covered when ALL of the following are met
Referenced in policy and background
Progress required for continuation; continuation may be considered for clearly documented exacerbations
Includes modalities (massage, mechanical stimulation, heat, cold, light, air, water, electricity, sound, exercises) and limited wound care/joint mobilization as applicable
Visit totals include rehabilitative and habilitative OT/PT in any combination
Applies to home health service coverage
Non-covered services include those specifically enumerated by the Bureau. This includes services that exceed the program visit limits — OT/PT services in excess of 20 visits per event and OT/PT services in excess of 30 visits for members in the Alternative Benefit Plan — and other exclusions such as experimental or investigational procedures, services provided to persons not eligible for Medicaid, services rendered by individuals who have not met Medicaid enrollment requirements, services covered under Workers' Compensation or Division of Vocational Rehabilitation Services, and situations involving separate payment for bundled procedure codes.
The policy also specifies that non-covered services include care when the member has reached maximum rehabilitation potential or when the member is non‑compliant with the documented treatment plan of care. Non-covered services under this chapter are not eligible for Department of Human Services Fair Hearings or Provider Desk/Document Reviews.
When the Medicaid member is a resident of a nursing facility, occupational and/or physical therapy services are not eligible for reimbursement as a direct billing to Medicaid at the time services are provided. Services furnished to nursing facility residents are governed by the facility rules (see Chapter 514) and should be claimed or reimbursed according to nursing facility payment arrangements rather than billed directly to Medicaid by the therapy provider.
Occupational and/or physical therapy services provided to Medicaid inpatients by therapists employed by the hospital are considered part of the facility's inpatient payment. Reimbursement for these services is included in the Diagnostic-Related Group (DRG) or the hospital's per diem rate and therefore will not be reimbursed separately. These inpatient services also do not require prior authorization under the DRG.
Therapy services required by residents of an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or a Psychiatric Residential Treatment Facility (PRTF) are reimbursed as part of the facility's all‑inclusive rate. If the facility does not provide the therapy on‑site and contracts with an outside provider, the facility remains responsible for reimbursement. Services provided under these arrangements are included in the ICF/IID or PRTF rate and must not be billed separately to Medicaid.
The policy identifies situations in which services are considered not medically necessary and therefore not covered. This includes services provided when a member has reached their maximum rehabilitation potential and services provided when a member is non‑compliant with the documented treatment plan of care. Claims for such services are not payable under the Medicaid program.
Codes, visit limits, and billing rules
| No codes listed |
Bill one visit per date of service (all modalities count as one)
Bill therapy as one visit per date of service: on any date when a member receives therapy, all modalities provided that day must be billed as a single visit (enter '1' for that date of service) and those modalities must be documented on the claim form.
- All modalities provided on the date of service count together as one visit and must be billed as '1' on the claim form.
- Modalities provided on that date must also be documented on the claim form.
Prior authorization, documentation, and denial risks
Prior authorization required for excess visits and continuation
Submit prior authorization requests for any services beyond the benefit limits and for continuation of therapy through the BMS UMC web-based portal; the UMC performs medical necessity review using nationally accredited criteria.
Prior authorization references (State Plan & Code)
See West Virginia State Plan sections and attachments referenced in the policy for related authority and benefit definitions; the policy cites specific State Plan sections and attachments and West Virginia State Code provisions.
- State Plan: sections 3.1-A(11)(a) and (b), 3.1-B(11)(a)
- Supplement 2 to attachments 3.1-A and 3.1-B(11)(a) and (b)
- Reimbursement: 4.19-B(11)(a) and (b)
- Attachment 3.1-L (Alternative Benefits Plan)
- WV State Code Chapter 30, Article 20
Submit clinical documentation and IEP for additional visits
Document and submit additional clinical documentation and an Individualized Education Program (IEP), if applicable, to the UMC when requesting additional visits beyond initial approval.
UMC uses accredited medical necessity criteria for reviews
Use nationally accredited, evidence-based criteria (such as InterQual) or other BMS-approved medical appropriateness criteria during prior authorization review; requests must be submitted to the UMC for medical necessity determination.
Document progress, compliance, home regimen, frequency/duration
Therapists must document progress/improvement, member compliance or noncompliance, the home regimen plan, and the frequency and duration of visits/modalities; submit this documentation when requesting continuation of services.
Keep a written Plan of Care and document modalities per visit
Maintain a written Plan of Care that outlines the progression of therapy and the modalities to be used; document modalities provided on each visit (date of service) on the claim form.
Denial triggers: excess visits and non‑enrolled/non‑eligible providers
Claims will be denied for services that exceed visit limits, and for services provided by non‑enrolled providers or to persons not eligible for Medicaid; the policy also excludes services covered by Workers' Compensation or DVR.
- Excess of 20 visits per event (combined OT/PT, osteopathic manipulation, chronic pain, chiropractic) will be denied
- Alternative Benefits Plan excess beyond 30 visits per calendar year will be denied
- Services by providers not enrolled in Medicaid or to non‑Medicaid eligible persons will be denied
- Services covered under Workers' Compensation or Division of Vocational Rehabilitation Services are excluded
Policy background
Occupational therapy (OT) and physical therapy (PT) are therapeutic services to evaluate and treat functional impairments and to restore or improve a member's ability to perform activities of daily living. Modalities may include massage, thermal agents (heat/cold), light, electrical stimulation, mechanical or acoustic agents, aquatic therapy, exercise, joint mobilization, neuromuscular‑skeletal testing, wound care, adaptive equipment training, and ADL retraining as clinically indicated. Services must be reasonable and necessary, provided by Medicaid‑enrolled and appropriately licensed therapists in accordance with 42 CFR 440.110 and West Virginia law, and documented in a written Plan of Care that outlines frequency, duration, modalities used, and measurable progress goals.
Defined terms
Policy revision history
Chapter 515 Occupational Therapy and Physical Therapy added language to specify services included in the visit calculation (Entire Chapter).
Policy 515.1 (Entire Chapter) updated with new effective date and updated hyperlinks; replaced title and effective date for the chapter effective 2024-09-01.
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