Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, precertification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective February 1, 2022, the Texas Health and Human Services Commission (HHSC) will transition certain COVID-19 flexibilities to interim guidance in line with House Bill (H.B.) 4 (87th Legislature, Regular Session, 2019). For physical therapy (PT), occupational therapy (OT), and speech therapy (ST) services, the guidance provided in the COVID-19 article titled “Claims for Telehealth Service for Occupational, Physical, and Speech Therapy” will end effective January 31, 2022.
This article will serve as interim guidance for reimbursement of PT, OT, and ST services provided by synchronous audiovisual technology until future Texas Medicaid Provider Procedures Manual updates are finalized.
For the following PT, OT, and ST services, per standards of care, telehealth must be clinically appropriate, safe, and agreed to by the client receiving services or by the legally authorized representative (LAR). Telehealth requires consent from the client or the client’s parent or LAR. Verbal consent is permissible and should be documented in the client’s medical record. Telehealth may require participation of a parent or caregiver to assist with the treatment. Providers must be able to defer to the needs of the person receiving services, allowing the mode of service delivery (audiovisual or in-person) to be accessible, person- and family-centered, and primarily driven by the person in service’s choice and not provider convenience.
Important: Texas Medicaid does not reimburse for PT, OT, or ST delivered through telephone (audio-only).
Synchronous Audiovisual PT, OT, and ST Evaluation and Treatment
Effective February 1, 2022, HHSC authorizes providers to submit claims for reimbursement of the following services by synchronous audiovisual technology.
Evaluation, reevaluation, and treatment for the following procedure codes may be reimbursed when delivered by telehealth as determined clinically appropriate by the rendering therapist and in compliance with each discipline’s rules:
|
Description of Services |
Procedure Codes |
|
Physical Therapy Evaluations – Low, Moderate, and High Complexity |
97161, 97162, 97163 |
|
Physical Therapy Evaluation – Re-evaluation |
97164 |
|
Occupational Therapy Evaluation – Low, Moderate, and High Complexity |
97165, 97166, 97167 |
|
Occupational Therapy Re-evaluation |
97168 |
|
Therapeutic Exercises |
97110 |
|
Neuromuscular Re-education |
97112 |
|
Gait Training |
97116 |
|
OT or PT Group Therapy |
97150 |
|
Therapeutic Activities |
97530 |
|
Self-care/Home Management Training |
97535 |
|
Community Reintegration – use only with other therapeutic procedure codes |
97537 |
|
Physical Performance Test or Measurement |
97750 |
|
Speech Evaluations |
92521, 92522, 92523, 92524, 92610 |
|
Speech Therapy Re-evaluation |
S9152 |
|
Services for Speech, Language, Voice, Communication, Auditory Processing Disorder Treatment |
92507 |
|
Speech Group Therapy |
92508 |
|
Swallowing/Oral Dysfunction Treatment |
92526 |
Note: Providers must use modifier 95 to indicate remote delivery. Providers are reminded to use the required modifiers GP, GO, and GN on all claims for physical, occupational, or speech therapy treatment. Treatment notes should indicate that remote delivery of the service is clinically appropriate per the rendering therapist’s professional judgement.
PT, OT, and ST In-person Evaluation and Treatment
Specialized evaluations required for the provision of new complex rehabilitation technology, such as power mobility and adaptive seating systems or augmentative communication devices, require the physical presence of the speech-language pathologist, the occupational therapist, or the physical therapist and should not be delivered by telehealth.
The following procedure codes will not be reimbursed if delivered by synchronous audiovisual or audio-only technology:
|
Description of Services |
Procedure Codes |
|
Wheelchair Assessment and Training |
97542 |
|
Orthotic Management and Training, Initial Encounter |
97760 |
|
Prosthetic Training of Either or Both Upper Extremity and Lower Extremity, Initial Encounter |
97761 |
|
Orthotic/Prosthetic Management and/or Training, Subsequent Encounter |
97763 |
|
Traction |
97012 |
|
Electrical Stimulation (Unattended) |
97014 |
|
Vasopneumatic Device |
97016 |
|
Paraffin Bath |
97018 |
|
Whirlpool |
97022 |
|
Diathermy |
97024 |
|
Infrared |
97026 |
|
Ultraviolet |
97028 |
|
Electrical Stimulation |
97032 |
|
Iontophoresis |
97033 |
|
Contrast Baths |
97034 |
|
Ultrasound |
97035 |
|
Hydrotherapy |
97036 |
|
Ultrasound |
97035 |
|
Aquatic Therapy |
97113 |
|
Therapeutic Massage |
97124 |
|
Manual Therapy |
97140 |
|
Unlisted Rehabilitation Service |
97799 |
Texas licensure rules for speech-language pathology, occupational therapy, and physical therapy address the provision of telehealth by two-way audiovisual platforms. Telehealth therapy services must be delivered within the provision of current licensure requirements found on the Occupational Therapy Rules, Physical Therapy Rules, and Speech-Language Pathologists and Audiologists Administrative Rules webpages.
Therapy assistants may provide telehealth and receive supervision within limits outlined in each discipline’s rules. Providers should refer to state practice rules and national guidelines regarding supervision requirements for each discipline.
Providers can refer to the Texas Medicaid Provider Procedures Manual, Telecommunication Services Handbook, for additional information about Texas Medicaid telemedicine and telehealth benefits and the Physical Therapy, Occupational Therapy, and Speech Therapy Handbook for more information about current PT, OT, and ST benefits.
For more information, call the TMHP Contact Center at 800-925-9126.