February 01, 2022

Medicare new prior authorization requirement that includes clinical submission

Effective Feb. 1, 2022, UnitedHealthcare will require you to obtain prior authorization for PT, OT and ST services delivered at multi-disciplinary offices and outpatient hospital settings. These prior authorization requirements apply to patients new to therapy and those who are currently receiving therapy. To confirm that this requirement applies to your patient please check the group number on their Member Identification Card and compare it to the in-scope plans for this requirement.

You may also review the latest FAQ that includes important information about how to confirm which patients are subject to this requirement.

Note: The initial evaluation for your patient does NOT require prior authorization. However, in order to receive reimbursement for the initial evaluation, the results from the initial evaluation, (the patient assessment form) must be submitted for review. The initial patient evaluation will be used to assist in the request for follow-up treatment which does require prior authorization.

See the specific codes for affected services.

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CPT Code Description
97012 Application of a modality to 1 or more areas; traction, mechanical
97016 Application of a modality to 1 or more areas; vasopneumatic devices
97018 Application of a modality to 1 or more areas; paraffin bath
97022 Application of a modality to 1 or more areas; whirlpool
97024 Application of a modality to 1 or more areas; diathermy (e.g., microwave)
97026 Application of a modality to 1 or more areas; infrared
97028 Application of a modality to 1 or more areas; ultraviolet
97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
97033 Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
97034 Application of a modality to 1 or more areas; contrast baths, each 15 minutes
97035 Application of a modality to 1 or more areas; ultrasound, each 15 minutes
97036 Application of a modality to 1 or more areas; hubbard tank, each 15 minutes
97039 Unlisted modality (specify type and time if constant attendance)
97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112 Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion). 
97139 Unlisted therapeutic procedure (specify)
97140 Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes
97150 Therapeutic procedure(s), group (2 or more individuals)
97161 Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to-face with the patient and/or family.
97162 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97163 Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family.
97164 Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family.
97165 Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97166 Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.
97167 Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.
97168 Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes
97535 Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes
97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes
97542 Wheelchair management (e.g., assessment, fitting, training), each 15 minutes
97545 Work hardening/conditioning; initial 2 hours
97546 Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure)
97750 Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.
97755 Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes
97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes.
97761  Prosthetic training, upper and/or lower extremity(s), each 15 minutes 
97799 Unlisted physical medicine/rehabilitation service or procedure
G0281 Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care
G0282 Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281
97168 Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes
97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes
97535 Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes
97537 Community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes
97542 Wheelchair management (e.g., assessment, fitting, training), each 15 minutes
97545 Work hardening/conditioning; initial 2 hours
97546 Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure)
97750 Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes.
97755 Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes
97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes.
97761  Prosthetic training, upper and/or lower extremity(s), each 15 minutes 
97799 Unlisted physical medicine/rehabilitation service or procedure

How do I request authorization?
For dates of service on or after Feb. 1, 2022,
use the PAAN system to submit clinical information. To request authorization for your planned PT, OT and ST services click on the PT.OT.ST Outpatient Therapy Transactions Option.  Reminder, your initial evaluation does not require authorization. 

Medical necessity reviews are conducted by licensed medical professionals, including physical therapists, occupational therapists and speech-language pathologists. You and your patient will be notified of our review results.

Will these requirements affect claims? 
Yes. If you don’t obtain a prior authorization online before performing a PT, OT or ST procedure, your claim for that service will be denied and the patient cannot be billed for the service.

Review the medical necessity guidelines used to help facilitate the medical necessity determinations for these services.

Outpatient rehabilitation therapy physical therapy, occupational therapy and speech-language pathology services conditions of coverage
Outpatient therapy services are covered in accordance with certain conditions as outlined in the Medicare Benefit Policy Manual, Chapter 15, §220.1 – Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services (accessed April 8, 2021).

Questions?
Contact Provider Services at 866-416-6594.

CPT® is a registered trademark of the American Medical Association. 
PCA-22-00584-VC-News