Does 97130 require prior authorization?

No, 97130 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 97130?

Medicare facility rate: $18.37. Non-facility rate: $21.04. Work RVU: 0.48.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.48

Facility

$18.37

Non-Facility

$21.04

The patient's medical record must contain documentation that fully supports the medical necessity of the services provided.
For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.
Diagnosis code(s) reported on the claim must best describe the patient's condition for which the service was performed; missing or invalid codes will result in claim return.
Because CPT does not define a re-evaluation code for speech-language pathology, use the evaluation CPT code to report re-evaluations and document minutes the same as for initial evaluations.

Speech-language pathology services are covered for diagnosis and treatment of speech and language disorders that result in communication disabilities.
Speech-language pathology services are covered for diagnosis and treatment of swallowing disorders (dysphagia).
Services are covered when provided by a qualified speech-language pathologist who holds a Certificate of Clinical Competence (CCC-SLP) or is in the clinical fellowship year (CFY) accumulating supervised experience required for certification.
Services are covered when they are a specific and effective treatment under accepted standards of medical practice for the patient's condition.
Services are covered when the level of complexity or the patient's condition requires that the services can be safely and effectively performed only by or under the supervision of a qualified therapist (skilled care required).
Rehabilitative therapy is covered when the patient has potential to improve or is improving, maximum improvement has not been attained, and anticipated improvement is attainable in a reasonable and generally predictable period.

A52866 — Billing and Coding: Speech-Language Pathology

J06

L33580 — Speech-Language Pathology

J06

L33631 — Outpatient Physical and Occupational Therapy Services

J06

A56566 — Billing and Coding: Outpatient Physical and Occupational Therapy Services

J06

A54111

Ask Verity about documentation requirements, denial risks, or coverage in your state.