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Physical Medicine & Rehabilitation: PT, OT and Evaluation and Management Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans

Overview

This policy describes which codes will and will not be reimbursed for physical and occupational therapy evaluation services and the use of the GO, GP, CO and CQ modifiers. 

Policy Codes

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  • 97161
  • 97164
  • 97165
  • 97168
  • 98970
  • 98972
  • 99091
  • 99201
  • 99499
  • G2061
  • G2063
* COMM-Physical-Med-Rehab-PT-OT-and-Evaluation-Mgmt-Policy.pdf
Click to Download: Physical Medicine & Rehabilitation: PT, OT and Evaluation and Management Policy - Reimbursement Policy - UnitedHealthcare Commercial Plans

Reimbursement Guidelines

Physical and Occupational Therapists will be reimbursed for the appropriate use of Current Procedural Terminology (CPT ®) codes 97161-97164 or 97165-97168.  Physical and Occupational Therapy Assistants will not be reimbursed for CPT codes 97161-97164 or 97165-97168. 

Consistent with coding guidelines of the Centers for Medicare and Medicaid Services (CMS), UnitedHealthcare will not reimburse Physical and Occupational Therapists or Physical and Occupational Therapy Assistants for CPT evaluation and management codes 98970-98972, 99091, 99201-99499 or Healthcare Common Procedure Coding System.

(HCPCS) codes G2061-G2063.

Effective for claims with dates of service on or after July 1, 2020, UnitedHealthcare aligns with CMS and requires Healthcare Common Procedure Coding System (HCPCS) modifiers GO and GP to be reported with the codes designated by CMS as always therapy services to distinguish the discipline of the plan of care under which the service is delivered.  Please refer to the Procedure to Modifier Policy for additional information.

In accordance with CMS, effective for claims with dates of service on or after January 1, 2020, the CQ and CO modifiers are required to be used for services furnished In Whole or In Part by a Physical Therapy Assistant (PTA) or Occupational Therapy Assistant (OTA).  These modifiers should be used on the claim line of the service, alongside the respective GP or GO therapy modifier.  The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy modifier.

The CQ and CO modifiers do not apply to services furnished by PTAs and OTAs that are incident to the services of physicians or nonphysician practitioners.

Other reimbursement policies that address reimbursement for the codes reported, may also apply.