On December 18, 2017, Humana announced they would no longer require preauthorization for outpatient physical, speech and occupational therapy services for patients with commercial and Medicare Advantage (MA) coverage. Unfortunately, nothing lasts forever. Effective with dates of service on and after I hope you found this article helpful and informative. Thank you for being a Gold Member!

This week, I will provide 3 billing scenario’s that can be applicable to either outpatient physical therapy or outpatient occupational therapy services and provide the billing answer for Medicare beneficiaries and those insurance carriers that follow the Medicare Program billing rules (i.e. “8-minute rule) and will also provide the billing answer for those insurance carriers that do not follow the Medicare Program billing rules, rather, follow the definition of a substantial portion of a time-based CPT per the American Medical Association (AMA). Two articles that you may want to read prior to continuing on with this article are “What CPT

If you provide outpatient physical, occupational and/or speech therapy services in the state of Florida to patients who are covered by UnitedHealthcare Community Plan of Florida, you will want to read this article. Prior authorization requirements for Florida effective

On May 23, 2019, House Bill (HB) 29 passed the Texas Senate and on June 14, 2019, Governor signed the bill into law. HB 29 will provide Texas residents the ability to have Direct Access for physical therapy services with an effective date of September 1, 2019. Highlights of HB 29 and Direct Access include: A physical therapist may treat a patient for an injury or condition in a manner described by Section 453.005 without a referral if the physical therapist:  

UnitedHealthcare (UHC) Community Plan is adding 3 states (in addition to the 4 previously announced) that will require prior authorization prior to initiating physical, occupational and/or speech therapy services. In addition, UHC Community Plan is adding site of service medical necessity reviews for all speech, occupational and physical therapy services provided in a hospital outpatient setting in 2 of the 3 states. The new impacted states are

On July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule for calendar year (CY) 2020 for services paid under the Medicare Physician Fee Schedule (MPFS). This proposed rule does impact providers of outpatient physical, occupational and speech therapy services in all outpatient therapy settings that does include private practices, hospital outpatient departments (including Medicare beneficiaries under Observation status and in the Emergency Department and do not get admitted to the hospital), skilled nursing facilities, rehabilitation agencies, comprehensive outpatient rehabilitation facilities and home health agencies providing outpatient therapy in a Medicare beneficiaries home. Highlights of

UnitedHealthcare Community Plan has announced they will implement prior authorization for outpatient physical, occupational and speech therapy services in select states beginning as early with dates of service on and after August 1, 2019. In addition, UnitedHealthcare Community Plan has announced they will be conducting site of service medical necessity reviews for all speech, occupational and physical therapy services in select states. Effective with dates of service on and after August 1, 2019, the following states will be required to obtain prior authorization before implementing outpatient physical, occupational and/or speech therapy services:

UnitedHealthcare Community Plan has issued a revised coverage determination guideline for outpatient physical and occupational therapy. This policy applies to the following 12 states: