TMPPM 2009 > Texas Medicaid Services > Physical Therapists/Independent Practitioners > Reimbursement

35.2.1 Benefits and Limitations

Payments for PT are limited to acute disorders of the musculoskeletal system or exacerbations of chronic disorders necessitating PT to restore function.

Claims must include the AT modifier to represent 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. Such services must be made available 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 97535, 97537, 97542, 97760, and 97762 are only payable for clients 20 years of age or younger.

Procedure codes 97010, 97265, 97545, 97546, 97770, 97780, and 97781 are not benefits.

Procedure codes 97750 and 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 97001 is payable once per 6 months, any provider. Procedure code 97002, is payable once per month, any provider. Procedure codes 97001 and 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 2 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 who have chronic musculoskeletal or neuromusculoskeletal conditions, or other chronic conditions that require medically necessary physical therapy.

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.

Clients 21 years of age or older receive PT through Texas Medicaid (Title XIX) Home Health Services.

Refer to: "Home Health Services" for information about PT services provided in the home setting.

"THSteps Medicaid Children's Services (Comprehensive Care Program [CCP])" for information about PT, occupational therapy (OT), and speech language-pathology (SLP) services.