97168
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.96
Facility
$68.47
Non-Facility
$68.47
Documentation Required
- When a referring/ordering physician is required, the referring/ordering physician’s name and NPI must be reported on the claim.
- Diagnosis code(s) must best describe the patient’s condition for which the service was performed and a valid ICD-10-CM code is required on the claim.
- For an evaluation-only episode, the evaluation serves as the plan of care if it contains a diagnosis or a description from which a referring physician/NPP may determine a diagnosis, and the referral/order certifies the evaluation is needed.
- When a qualified professional allows a student to participate, the qualified professional must be present in the room, direct the service and make skilled judgments, not be treating another patient or performing other tasks, and must sign all documentation appropriately.
Key Coverage Criteria
- Skilled therapy services are covered when the skills of a qualified therapist are necessary to improve the patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration.
- Rehabilitative therapy is covered when therapist skills are necessary to safely and effectively furnish a recognized therapy service with the goal of improving an impairment or functional limitation.
- Maintenance therapy is covered only when an individualized clinical assessment documents that specialized judgment, knowledge, and skills of a qualified therapist are necessary to perform the maintenance program safely and effectively.
- Physical therapy (CPT 97161-97163) and occupational therapy (CPT 97165-97167) evaluations are covered; when an evaluation is the only service in an episode, the evaluation serves as the plan of care if it contains a diagnosis or a description sufficient for the referring physician/NPP to determine a diagnosis.
- Therapy services are covered when the medical record and claim consistently and accurately document that the services are covered and medically necessary.
- Therapy is covered when the patient has impairments and functional limitations that require the unique skills of a clinician (therapist) to improve functioning.
20 Active Policies
A56566 — Billing and Coding: Outpatient Physical and Occupational Therapy Services
J06
L33631 — Outpatient Physical and Occupational Therapy Services
J06
CGS-L34049 — Outpatient Physical and Occupational Therapy Services
J18 MAC Part B
PALMETTO-L38033 — Cervical Disc Replacement
JJ Part B
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.