Therapeutic Max Billing Units

Key Coverage Information for PT - Max Billing Units

Most major insurance payers, including Aetna, Medicare, and UHC, have implemented policies limiting physical medicine and rehabilitation services to a maximum of four (4) units per visit. This typically equates to one hour of treatment per day. Submitting claims that exceed this threshold may result in denials for exceeding the maximum allowed units.

Common CPT codes impacted: 97032, 97110, 97112, 97113, 97116, 97124, 97130, 97530, 97533, 97535, 97537, 97542, 97760, 97761, 97763.

Here are links to payer-specific policies for your reference:

• UnitedHealthcare Policy – Max Frequency per Day
• Medicare Local Coverage Article (LCA) – Therapy Cap Guidance
• Aetna OfficeLink: Expanded Modality Limit (pg 3)     

Special Note regarding: Blue Cross Blue Shield (BCBS)

BCBS plans vary slightly by state and carrier (since many operate independently), but in most cases:

• 4 units is the routine reimbursement threshold for outpatient therapy.
• Some plans may allow more if clinical documentation supports medical necessity.
• Preauthorization or plan-specific policies may apply for high-frequency therapy.

What This Means for Your Practice:

Additional units exceeding 4 units per patient, per visit will be denied.

The most commonly reimbursed therapy units total 60 minutes of medically necessary, skilled care.

Units billed beyond this threshold will require additional documentation to support medical necessity.

Need to Bill More Than 4 Units?

If a patient’s condition warrants more than four units of service during a single visit:

A Letter of Medical Necessity must be submitted, detailing:

• Clinical justification for extended treatment time.
• Specific patient needs and complexity.
• Supporting progress notes and treatment plan.

Please provide this documentation to Zaya Care so we can assist in submitting an appeal on your behalf.

Best Practices:

Plan for up to 60 minutes of billable services per session unless clinical justification exists.

Document thoroughly in the medical record, particularly for more complex or prolonged care.

Coordinate with Zaya Care for support on any necessary appeals and documentation submission.