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December 2016 Texas Medicaid Provider Procedures Manual

Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook : 6 Adult Services : 6.3 PT, OT, and ST Procedure Codes

6.3
Time-based PT, OT, and ST treatment procedure codes that may be billed in multiple quantities of 15 minutes each are limited to one hour per date of service per discipline (4 units). Procedure codes listed in the following table must be billed in 15 minute increments:
 
Time-based PT and OT treatment procedure codes that may be billed in multiple quantities of 15 minutes each are limited to thirty minutes per date of service per discipline (2 units). Procedure codes 97034 and 97035 must be billed in 15-minute increments.
Note:
Time-based PT and OT treatment procedure codes that may be billed in multiple quantities of 15 minutes each are limited to forty-five minutes per date of service per discipline (3 units). Procedure code 97036 must be billed in 15-minute increments.
 
 
If the therapy services billed exceed one hour (four units a day), the claim will be denied, and may be appealed. On appeal, the provider must meet the following conditions:
For clients who are 21 years of age and older, when physical or occupational group therapy is administered, providers should bill procedure code 97150 for each member of the group.
A client may receive therapy in more than one discipline (physical, occupational, or speech) in the outpatient, office or home setting in one day.
If a therapy evaluation or reevaluation procedure code and like therapy procedure codes are billed for the same date of service by any provider, the like therapy evaluation or reevaluation will be denied.
An evaluation or reevaluation performed on the same day as therapy from a different therapy type must be performed at distinctly separate times to be considered for reimbursement.
Physical therapy provided in the nursing home setting is limited to the nursing facility because it must be made available to nursing home 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 home facilities should refrain from admitting clients who need goal directed therapy if the facility is unable to provide these services.
Procedure codes for PT, OT, ST evaluations are payable once every three years to the same provider.
For acute services, PT, OT, ST reevaluations are reimbursed once every 60 days to any provider when a recertification of services is planned.
Additional PT, OT, or ST evaluations or reevaluations exceeding the limits outlined in this handbook may be considered for reimbursement on appeal with documentation of one of the following:
The reevaluation is required for recertification of an existing authorization.
Licensed therapists of each therapy discipline must use the therapy assistant modifier to indicate the services rendered by licensed therapy assistants while attending to Medicaid clients.
The therapist must submit on the claim the UB modifier to indicate the PT, OT, or ST service(s) provided by a PT, OT, or speech-language pathology assistant(s) in a 24-hour period to Medicaid clients:
 
This modifier is to be utilized as indicated with all physical, occupational, and speech therapy treatment procedure codes.
Claims for co-treatment services must be submitted with modifier U3:
 

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