TMPPM 2008 > Texas Medicaid Services > Physical Therapists/Independent Practitioners > Reimbursement

35.2.1 Benefits and Limitations

PT is the use of physical agents such as heat, massage, electricity, traction, or exercises in the treatment of disease. Payments for PT are limited to acute disorders of the musculoskeletal system or exacerbations of chronic disorders necessitating PT to restore function. The acute modifier AT must be billed for payment to be made. The AT modifier represents treatment provided for an acute condition or an exacerbation of a chronic condition that persists less than 180 days from the start date of therapy. If the condition persists for more than 180 days from the start of therapy, the condition is considered chronic, and treatment is no longer considered acute. Providers may file an appeal for claims denied as being beyond the 180 days of therapy with supporting documentation that the client's condition has not become chronic and the client has not reached the point of plateauing.

Plateauing is defined as the point that maximum improvement has been documented and more improvement ceases.

Examples of what may be considered acute are as follows:

•A new injury.

•Therapy before or after surgery.

•Acute exacerbations of conditions such as rheumatoid arthritis.

•Interventions such as a newly implanted intrathecal pump to decrease spasticity or Botulinum Toxin Type A injections.

PT, including functional evaluations, must be provided according to the current written orders of a physician (within 60 days) and based on medical necessity. It may be performed by auxiliary personnel under the direct supervision of the physician or the independently practicing physical therapist.

Payment cannot be made to a provider or an independently practicing physical therapist who provides physical medicine to a resident of a nursing facility. These services must be made available to nursing facility residents on an as needed basis and must be provided directly by the staff of the facility or furnished by the facility through arrangements with outside qualified resources. Nursing facilities must refrain from admitting clients who need goal-directed therapy, if the facility is unable to provide these services.

The following procedure codes are limited to once per day:

The following procedure codes may be paid in multiple 15-minute quantities:

Procedure codes 1-97535, 1-97537, 1-97542, and 1-97760 are only payable for clients younger than 21 years of age.

Procedure codes 1-97010, 1-97265, 1-97545, 1-97546, 1-97770, 1-97780, and 1-97781 are not a benefit.

Procedure codes 1-97750 and 1-97762 are comprehensive codes and include an office visit. If an office visit is billed for the same day by the same provider, the office visit will be denied as part of another procedure billed for the same day. Procedure code 1-97762 is only payable for clients 20 years of age or younger.

Procedure code 1-97001 is payable once per six months, any provider, same facility. Procedure code 1-97002, is payable once per month, any provider, same facility. Procedure codes 1-97001 and 1-97002 are not payable on the same day as the following procedure codes:

Procedure codes that may be billed in multiple quantities (i.e., 15 minutes each) are limited to a total of two hours per day of individual, group, or a combination of individual and group therapy.

PT services that are not benefits of the regular Texas Medicaid Program may be benefits under THSteps-CCP when they are provided to clients with musculoskeletal or neuromusculoskeletal conditions.

CCP is for Medicaid THSteps-eligible clients who are 20 years of age or younger. CCP eligibility ends on the day of the client's 21st birthday.

Refer to: "Texas Medicaid (Title XIX) Home Health Services" for information about authorization requirements and coverage or noncoverage of physical medicine and rehabilitation codes in the home.