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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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Referral

In order for a student to receive PT through SHARS, the name and complete address or the provider identifier of the licensed physician who prescribes the PT must be provided.

Providers

PT must be provided by a professional who is licensed by the Texas Board of Physical Therapy Examiners or a licensed physical therapist assistant (LPTA) acting under the supervision of a qualified physical therapist.

Services

PT must be provided by a professional who is licensed by the Texas Board of Physical Therapy Examiners or a licensed physical therapist assistant (LPTA) acting under the supervision of a qualified physical therapist.

Evaluations

PT evaluation includes evaluating the student’s ability to move throughout the school and to participate in classroom activities and the identification of movement dysfunction and related functional problems.

PT evaluation is billable on an individual (procedure code 97161, 97162, or 97163) basis only. Procedure codes 97161, 97162, and 97163 may be submitted for initial evaluations and reevaluations. PT is billable on an individual (procedure code 97110) or group (procedure code 97150) basis.

If an evaluation is performed over several days, the provider must submit the same evaluation procedure code for each evaluation session. The procedure code submitted must reflect the complexity level of the entire evaluation.

The therapist who performs the evaluation should use professional clinical judgment to decide which evaluation code to use. The selection of low (procedure code 97161), moderate (procedure code 97162), or high complexity (procedure code 97163) evaluation codes must be based on professional clinical judgment and may not be made by staff other than the rendering therapist.

Session Notes

Session notes are not required for procedure codes 97161, 97162, and 97163; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the activity that was performed (e.g., PT evaluation).

Session notes are required for procedure codes 97110 and 97150. Session notes must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student observation, and the related IEP objective.

Reimbursement

POS

Procedure Code

Individual or Group

PT or PTA

1, 2, or 9

97161, 97162, and 97163

Individual

PT

1, 2, or 9

97110 with modifier GP

Individual

PT

1, 2, or 9

97110 with modifier GP and U1

Individual

PTA

1, 2, or 9

97150 with modifier GP

Group

PT

1, 2, or 9

97150 with modifier GP and U1

Group

PTA

Place of Service: 1=office; 2=home; 9=other locations

The recommended maximum billable time for PT evaluation is three hours, which may be billed over several days within a 30 day period. The recommended maximum billable time for direct therapy (individual or group) is a total of one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

Citation

Texas Medicaid Provider Handbook

Children’s Services

August 2019

Referral

In order for a student to receive PT through SHARS, the name and complete address or the provider identifier of the licensed physician who prescribes the PT must be provided.

Providers

PT must be provided by a professional who is licensed by the Texas Board of Physical Therapy Examiners or a licensed physical therapist assistant (LPTA) acting under the supervision of a qualified physical therapist.

Services

PT must be provided by a professional who is licensed by the Texas Board of Physical Therapy Examiners or a licensed physical therapist assistant (LPTA) acting under the supervision of a qualified physical therapist.

Evaluations

PT evaluation includes evaluating the student’s ability to move throughout the school and to participate in classroom activities and the identification of movement dysfunction and related functional problems.

PT evaluation is billable on an individual (procedure code 97161, 97162, or 97163) basis only. Procedure codes 97161, 97162, and 97163 may be submitted for initial evaluations and reevaluations. PT is billable on an individual (procedure code 97110) or group (procedure code 97150) basis.

If an evaluation is performed over several days, the provider must submit the same evaluation procedure code for each evaluation session. The procedure code submitted must reflect the complexity level of the entire evaluation.

The therapist who performs the evaluation should use professional clinical judgment to decide which evaluation code to use. The selection of low (procedure code 97161), moderate (procedure code 97162), or high complexity (procedure code 97163) evaluation codes must be based on professional clinical judgment and may not be made by staff other than the rendering therapist.

Session Notes

Session notes are not required for procedure codes 97161, 97162, and 97163; however, documentation must include the billable start time, billable stop time, total billable minutes, and must note the activity that was performed (e.g., PT evaluation).

Session notes are required for procedure codes 97110 and 97150. Session notes must include the billable start time, billable stop time, total billable minutes, activity performed during the session, student observation, and the related IEP objective.

Reimbursement

POS

Procedure Code

Individual or Group

PT or PTA

1, 2, or 9

97161, 97162, and 97163

Individual

PT

1, 2, or 9

97110 with modifier GP

Individual

PT

1, 2, or 9

97110 with modifier GP and U1

Individual

PTA

1, 2, or 9

97150 with modifier GP

Group

PT

1, 2, or 9

97150 with modifier GP and U1

Group

PTA

Place of Service: 1=office; 2=home; 9=other locations

The recommended maximum billable time for PT evaluation is three hours, which may be billed over several days within a 30 day period. The recommended maximum billable time for direct therapy (individual or group) is a total of one hour per day. Providers must submit documentation of the reasons for the additional time, if more than the recommended maximum time is billed.

Citation

Texas Medicaid Provider Handbook

Children’s Services

August 2019

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