Outpatient PT/OT Benefits

Health First Colorado covers physical and occupational therapy services provided in an outpatient setting. Services take place in the office, hospital, home, and other settings. Physical and occupational therapy (PT/OT) is also available through the Home Health Program and in the school as part of the School Health Services Program.

Who is eligible for outpatient PT/OT services?

All enrolled members are eligible to receive these services.

Reference the billing and policy manual for complete details.

What services are available?

A variety of CPT billing codes are available for billing. These include but are not limited to:

  • Evaluation
  • Individual and group therapeutic treatment
  • Assistive technology assessment
  • Cognitive skill development
  • Orthotics

 

Reference the billing and policy manual for complete details.

General Policies

  • All services must be medically necessary.
  • All services must have an approved plan of care associated with them.
  • All services must be ordered by an enrolled physician, physician assistant, or nurse practitioner.
    • Approved Individualized Family Service Plans (IFSPs) count as an order.
  • All claims must include the National Provider Identification (NPI) number of the enrolled provider who rendered the service.
  • All claims must include the NPI number of the enrolled provider who ordered the service.
  • Services provided to children in a school, with an IEP, must be reimbursed by the School District, not fee-for-service via the Provider Web Portal.
  • There are generally no co-pays applicable to this benefit. Co-pays are only required if the member is being treated in a hospital setting and is not a child (under age 19) or pregnant woman.

Reference the billing and policy manual for complete details.

What services are not covered?

Reference the billing and policy manual for complete details.

How do I become an enrolled provider?

As a Health First Colorado (Colorado's Medicaid Program) provider, you have the opportunity to improve the health and well-being of more than a million Coloradans. Health First Colorado is more than health insurance - it is a vital public service, helping almost one in five Colorado citizens stay healthy or move towards better health.

The enrollment process is online and begins on the Become a Provider page.

Enrollment in Managed Care networks is only required if the member being treated is in the Denver Health or Rocky Mountain Health Plan networks.

How are services reimbursed?

Professional outpatient PT/OT services are reimbursed according to the current Health First Colorado Fee Schedule. Reimbursement rates will vary by CPT code reported. The fee schedule shows the maximum allowed reimbursement for each CPT code. Submitted claims will be reimbursed according to 'lesser-of' pricing logic. This means that the line item will reimburse either at submitted charges or the fee schedule rate, whichever is lesser.

Hospital providers of physical and occupational therapy are subject to EAPG reimbursement methodology.

Providers must first enroll into the program to submit claims. Once they are enrolled, providers may submit claims directly by logging into the Provider Web Portal. Claims may be submitted by billing agencies on behalf of the provider.

Resources for enrollment and billing may be found at Provider Resources.

What's the difference between outpatient PT/OT and other settings?

  • The outpatient PT/OT benefit reimburses billing providers who are enrolled as clinics, non-physician practitioner groups, rehab agencies, hospitals, or as individual therapists. Services are reported using CPT codes. The professional claim type is used for all billing types except hospitals and some rehab agencies, which use the institutional claim type.
    Services may be rendered at the member's home and reported using CPT codes.
  • The Home Health Program reimburses providers who are enrolled as home health agencies. Different policies and billing requirements apply.
  • The School Health Services Program.
  • Nursing facilities provide PT/OT. They are reimbursed for this as part of their per-diem payment.

How does the Early Intervention program fit into Health First Colorado?

Members with an approved IFSP for PT/OT services still have their services covered by Health First Colorado. Coverage policy and limitations are not different for members with an approved IFSP. An approved IFSP may serve as an 'order for services', in lieu of a physician order.

Health First Colorado must be billed first for the member's PT/OT services as part of an IFSP. Early Intervention funding is only available for services not covered by Health First Colorado.

What's the difference between Rehabilitative and Habilitative services?

"Rehabilitative" means therapy that treats acute injuries and illnesses which are non-chronic conditions. Rehabilitative is therefore short-term in nature.

"Habilitative" means therapy that treats chronic conditions with the purpose of helping the member retain or improve skills and functioning that are affected by the chronic condition. Habilitative therapy may therefore be long-term in nature.

Reference the billing and policy manual for complete details.

Recent News and Updates

  • Check the Provider Bulletin index for all provider bulletins related to outpatient PT/OT.
  • CPT 97532 (cognitive skills development) is closed as of 12/31/2017. It should only be reported for dates of service prior to its closure. It has been replaced by an identical code HCPCS G0515 (cognitive skills development) effective 1/1/2018.
  • National Correct Coding Initiative (NCCI) billing edits affect this benefit. Providers should be familiar with the information found on the Medicaid.gov NCCI Website including the NCCI Policy Manual found there.

Benefit Limitations

  • A daily limit of five units of physical therapy services and five units of occupational therapy services is allowed, whether it is rehabilitative or habilitative. Some specific daily limits per procedure code apply.
  • Members may receive up to 48 units of any combination of PT/OT services per rolling 12-month period before a Prior Authorization Request (PAR) is required. Evaluation and orthotic services are not included in this limit. This equates to roughly twelve hours of therapy services (each unit of service being equal to 15 minutes).
    • Units of service exceeding the initial 48 units are not covered without an approved PAR.

Reference the billing and policy manual for complete details.

Benefit Limitation Frequently Asked Questions

What is the benefit limit for outpatient physical and occupational therapy (PT/OT)?

All members have a soft-limit of 48 units of service covered per rolling 12 months. This limit may be exceeded with an approved prior authorization request (PAR). Visit the ColoradoPAR web page to begin the authorization process.

Is it still necessary to check an adult's Benefit Plan to see if they are on the Alternative Benefit Plan (ABP) and would qualify for habilitative PT/OT?

No. All members have both rehabilitative and habilitative PT/OT covered. These therapies are both subject to the soft-limit of 48 units of service per rolling 12 months, with an approved prior authorization required to exceed it.

Is the 48-unit soft limit a combination of PT and OT?

Yes. The 48 units are any combination of PT and OT. For example, a member may have 40 units of PT and 8 units of OT when their soft limit is met.

Do I need to exhaust the patient's 48-unit soft limit before requesting prior authorization?

No. Providers may request a prior authorization from the onset of treatment moving forward.

How do I track my patient's available units of service?
  • The provider web portal displays the remaining benefit amount in the Eligibility tab. This number is calculated by counting all the paid units of service for PT/OT a member has incurred in the previous rolling 365 days. Once the soft limit of 48 units has been reached, an approved PAR is required to exceed it.
  • The counting function will calculate PT/OT units regardless of whether they were paid with a PAR on file. This means that after a PAR for PT/OT is exhausted members will not automatically have another 48 units of PT/OT available without a PAR. A full 365 days must elapse before the member has another 48 units of PT/OT available without requiring a PAR.
Is the 12-month period per calendar year, or does it start when therapy is initiated?

The 12-month period begins when therapy is initiated. The unit limit does not roll over to accumulate more than 48 available units in a 12-month period. Units are available until the limit of 48 has been reached in a 12-month period, then a PAR is required.

Are evaluations included in the 48-unit soft limit?

No. Procedure codes which count toward the 48-unit soft limit are in the 97XXX series, excluding evaluation and re-evaluation codes and 97755 for assistive technology assessments.

What if my patient has Third Party Liability or Medicare, and Health First Colorado is the secondary payer?

Any applicable unit of service which Health First Colorado makes payment on, will decrement against the 48-unit soft limit.

Are PT, OT, and Speech Therapy combined in the 48-unit soft limit?

No. Only outpatient PT and outpatient OT are part of the combined 48-unit soft limit. Outpatient speech therapy is not included.

Do any HCBS waiver services cover PT/OT?

No. HCBS waivers do not cover PT/OT. Outpatient physical and occupational therapies are a State Plan service.

Does the 48-unit soft limit affect PT/OT delivered via Home Health Agencies, School Health Services, or Inpatient Hospitals?
  • No. The 48-unit soft limit is only for PT/OT billed using CPT codes. PT/OT delivered through the School Health Services Program, in the inpatient hospital setting, or by a Home Health Agency using revenue codes is not affected by the limit.
  • PT/OT delivered by a Home Care Agency, billed using CPT codes, is subject to the 48-unit soft limit.

Policy Document

Applicable Rules, Regulations, and Statutes

All Medicaid Rules, Regulations, and Statutes apply to the administration of the Colorado Medical Assistance Program at large, which providers are required to follow. The following are specifically called out as the ones governing the outpatient PT/OT benefit:

  • 42 CFR 440.110 - Federal regulation describing the minimum requirements for a State Medicaid Agency to cover therapies.
  • 10 CCR 2505-10 8.200 and 8.300

 

Contact Information