G0159, Services performed by a qualified physical therapist, in the home health
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation for CPT 97010, 97018, 97022, and 97026 must reflect medical necessity and be made available to the MAC upon request.
- When billing a Z-code as the diagnosis, documentation must include the orthotic/prosthetic device name, date patient received the device, and date training/teaching began.
- Documentation for CPT 97542 wheelchair propulsion training must relate the training to expected, attainable functional goals for the patient and/or caregiver.
- Physical therapists must report patient contact time in 15-minute increments and bill using G0151 for physical therapy time reporting.
Key Coverage Criteria
- CPT 97110 may be billed when treating impairments of exercise tolerance due to cardiopulmonary impairments.
- CPT 97542 (wheelchair management training) may be billed for wheelchair propulsion training when the training is tied to expected functional goals attainable by the patient or caregiver.
- Home health physical therapy services are appropriate when based on impairments of body structure/function and demonstrable functional limitations consistent with the related LCD.
- Physical therapy, occupational therapy, or speech-language pathology services in the home setting are consideredmedically necessarywhen both of the criteria below are met:
- The individualâs therapy request meets medical necessity criteria under the physical, occupational, or speech-language pathology guidelines used by the plan;and
- The request meets medical necessity criteria for home health care outlined inCG-MED-23 Home Health.
10 Active Policies
ANTHEM-CG-REHAB-12, CG-REHAB-12 Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology
ANTHEM-CG-MED-23, CG-MED-23 Home Health
A53058, Billing and Coding: Home Health Physical Therapy
THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services
BCBSIL-THE803.010, Physical Therapy (PT) and Occupational Therapy (OT) Services
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.