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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Covered Services and Limitations

Criteria for Coverage

Physical and Occupational Therapy services are covered if they are medically necessary and meet the following criteria:

    • Treatment services must be ordered by an eligible prescribing provider (Physician, Physician Assistant, or Advanced Practice Nurse), and be started within 28 days of the date ordered.
    • Therapy services must be provided under a written treatment plan stating with specificity the member's condition, functional level, treatment objectives, the physicians order, plans for continuing care, modifications to the plan, and the plans for discharge from treatment.
    • In a manner consistent with accepted standards of medical practice, the service is found to be equally effective for a diagnosis or treatment compared to other less conservative or more costly treatment options.
    • The service has a base of evidence (including peer-reviewed literature and/or clinical experience and judgment) to support the clinical reasoning and selection of interventions.
    • The service is consistent with the member's confirmed diagnosis, and not in excess of the member's needs.

Service Limitations

A daily limit of five (5) units of physical therapy services and five (5) units of occupational therapy services is allowed, whether it is rehabilitative or habilitative. Some specific daily limits per procedure code apply.

Members may receive up to forty-eight (48) units of any combination of PT/OT services per rolling twelve (12) month period before a Prior Authorization Request (PAR) is required. Evaluation and orthotic services are not included in this limit. This equates to roughly twelve (12) hours of therapy services (each unit of service being equal to 15 minutes). This unit limit will be automatically enforced by the claims payment system by denying claims that exceed the limit.

Units of service exceeding the initial forty-eight (48) units are not covered without an approved PAR.

The twelve (12) month period begins when therapy is initiated. The unit limit does not roll-over to accumulate more than forty-eight (48) available units in a twelve (12) month period. Units are continually available until the limit of forty-eight (48) has been reached in a twelve (12) month period.

Non-Covered Services

A member may receive outpatient physical therapy and occupational therapy services during the same period and service dates, however, duplicate therapy (the same therapy performed by both an OT and PT) may not be performed on the same dates of service. Duplicated services (in general, and those overlapped between PTs and OTs) are not covered.

  • Art and craft activities for the purposes of recreation are not covered.
  • Hippotherapy/equine therapy is not covered.
  • Services that are experimental, investigational, or are provided as part of a clinical trial are not covered.
  • Supplies or pre-fabricated supplies that can be obtained from a medical supplier are not covered.
  • Services for conditions of chronic pain that do not interfere with the member's functional status and that can be treated by routine nursing measures are not covered.
  • Services not documented in the member's health care record are not covered.
  • Services not part of the member's plan of care are not covered.
  • Services specified in a plan of care that is not reviewed and revised as medically necessary by the member's physician (M.D. or D.O.), physician's assistant, nurse practitioner, or specified in an approved Individualized Family Service Plan (IFSP) for Early Intervention PT/OT are not covered.
  • A therapeutic service that is denied Medicare payment because of the provider's failure to comply with Medicare requirements is not covered.
  • Vocational or educational services, except as provided under IEP-related or waiver services are not covered.
  • Psychosocial services are not covered.
  • Educational, personal need and comfort therapies are not covered.
  • Record keeping documentation and travel time (the transport and waiting time of a member to and from therapy sessions) is not reimbursable.
  • Time spent for preparation, report writing, processing of claims, or documentation regarding billing or service provision is not reimbursable.
  • The following modalities are not covered under the occupational therapy benefit for Health First Colorado due to not meeting the medical necessity standard.
    • Eye Movement Desensitization and Reprocessing
    • Relationship Development Intervention
    • Internal Family Systems

Reference

Colorado Department of Health Care Policy & Financing

Physical and Occupational Therapy Billing Manual

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