[PT/OT] Payer-Specific Billing Guidelines

Summary

The following requirements are specific to Aetna, Anthem/Empire BCBS, Oscar, and United Healthcare based on their published Physical Therapy Coverage Guidelines. Always review the linked payer policies for the most current information.

Aetna

1. Timed Unit Limit

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

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. Assistant Modifiers

Aetna requires:

• CQ modifier when services are performed by a PTA

• CO modifier when services are performed by an OTA

3. Biofeedback Coverage

Aetna considers coverage of biofeedback therapy, including code 90901, when coverage criteria are met.

Refer to Aetna Biofeedback Coverage Guidelines for criteria and the list of covered ICD-10 codes.

Anthem / Empire BCBS

1. Additional NCCI Edit Requirement

Anthem has an outdated NCCI edit on file. In addition to the edits outlined in the PT coding article, Anthem requires modifier 59 on 97530 when billed with 97140 if the services were provided separately during distinct time periods.

2. Assistant Modifiers

Anthem requires:

• CQ modifier when services are performed by a PTA

• CO modifier when services are performed by an OTA

3. Strapping Coverage

Anthem considers coverage of strapping codes when the service is related to the hand, finger, ankle, foot, or toe.

Refer to Anthem Biofeedback Coverage Guidelines for coverage criteria and the list of ICD-10 codes.

Best practice is to indicate the side of the body treated by adding the RT or LT modifier when billing strapping.

Oscar

1. Assistant Modifiers

Oscar requires:

• CQ modifier when services are performed by a PTA

• CO modifier when services are performed by an OTA

2. Non-Covered Services

Oscar does not provide coverage for:

• Biofeedback

• Strapping

United Healthcare

1. Timed Unit Limit

United Healthcare limits PT and OT visits to a maximum of 4 timed units per visit.

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. Additional NCCI Edit Requirement

United Healthcare has an outdated NCCI edit on file. In addition to the edits outlined in the PT coding article, UHC requires modifier 59 on 97530 when billed with 97140 if the services were provided separately during distinct time periods.

3. Strapping Coverage

United Healthcare provides coverage for PT strapping codes.

Clinicians must indicate the side of the body treated by adding the RT or LT modifier.

4. Non-Covered Services

United Healthcare does not provide coverage for biofeedback.

Note:  Payer policies are subject to change. Zaya attempts to maintain the most up-to-date information in this article. Always refer to the linked payer policies to confirm current requirements.