Navigating Payer Specific Billing Requirements

In addition to the general coding requirements for PT billing discussed in Mastering PT Coding: Tips to Reduce Denials

Payers

• Aetna
• Anthem/Empire BCBS
• Oscar
• United Healthcare

Aetna

The below requirements are specific to Aetna plans based on their Physical Therapy Coverage Guidelines

1. Aetna limits PT and OT visits to a maximum of 4 timed units. 

• Timed Codes Include (but are not limited to): 97110, 97112, 97116, 97140, 97530, 97535, and 97750
• Untimed Codes Include (but are not limited to): 97161-97168, 97014/G0283, and 90901

2. Aetna does require the CQ or CO modifier when service are performed by a PTA or OTA (respectively).

3. Aetna does consider coverage of biofeedback therapy, including code 90901 if their coverage criteria are met.    The policy linked below includes the coverage criteria including a list of ICD-10 codes.

• Aetna Biofeedback Coverage Guidelines

Anthem/Empire BCBS

The below requirements are specific to Anthem/Empire plans based on their Physical Therapy Coverage Guidelines

1.  Anthem has an outdated NCCI edit on file, in addition to the edits outlined in the PT coding article, Anthem also requires that a 59 modifier be added to 97530 when it is billed with 97140 if those codes represent separate services provided during distinct time periods.

2. Anthem does require the CQ or CO modifier when service are performed by a PTA or OTA (respectively).

3. Anthem considers coverage of strapping codes when the service is related to the hand, finger, ankle, foot, or toe.  The policy linked below includes the coverage criteria including a list of ICD-10 codes.

• Aetna Biofeedback Coverage Guidelines
• It is best practice to indicate the side of the body being treated with strapping by using the RT or LT modifier

Oscar

The below requirements are specific to Anthem/Empire plans based on their Physical Therapy Coverage Guidelines

1. Oscar does require the CQ or CO modifier when service are performed by a PTA or OTA (respectively).

2. Oscar does not provide coverage for Biofeedback or Strapping

United Healthcare

1.  UHC limits PT and OT visits to a maximum of 3 timed units. 

• Timed Codes Include (but are not limited to): 97110, 97112, 97116, 97140, 97530, 97535, and 97750
• Untimed Codes Include (but are not limited to): 97161-97168, 97014/G0283, and 90901

2. UHC has an outdated NCCI edit on file, in addition to the edits outlined in the PT coding article, UHC also requires that a 59 modifier be added to 97530 when it is billed with 97140 if those codes represent separate services provided during distinct time periods.

3.  UHC does provide coverage for PT Strapping codes.

• The payer does require clinicians to indicate the side of the body being treated with strapping by using the RT or LT modifier

4.  UHC does not provide coverage for Biofeedback.

Note: Payer policies subject to change. Zaya will always attempt to include the most up to date information here, however you can always access the policies linked above for confirmation.