Does 98972 require prior authorization?

No, 98972 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 98972?

Medicare facility rate: $29.06. Non-facility rate: $34.40. Work RVU: 0.69.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

0.69

Facility

$29.06

Non-Facility

$34.40

The medical record must include the ordering provider's assessment as it relates to the patient's complaint for that visit.
Medical record must include relevant medical history, applicable comorbidities/medications, prior diagnostic imaging/testing results, prior therapy history for the same diagnosis, and results of pertinent tests/procedures.
All services ordered or rendered must be signed and dated; a legible identifier (handwritten or electronic signature) of the person(s) who provided the service is required.
Documentation must be legible, relevant, sufficient to justify medical necessity, and should paint a clear picture of impairments, functional limitations, prior functional level, and the skilled nature of treatment provided.

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.
Coverage requires an initial evaluation performed by a clinician that documents objective findings, baseline functional testing using standardized scales, realistic goals, and expected rehabilitation potential.
Services are covered when documentation provides objective measurements or assessment results that demonstrate clinical progress toward the patient's identified functional limitations.
Therapy is covered when documentation justifies the type, frequency, and duration of skilled therapy as medically necessary for the individual patient's condition.
Beneficiary is confined to the home to qualify for the Medicare home health PPS benefit.

A57067 — Billing and Coding: Outpatient Physical and Occupational Therapy Services

A57311 — Billing and Coding: Physical Therapy - Home Health

L34049 — Outpatient Physical and Occupational Therapy Services

L33942 — Physical Therapy - Home Health

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