Temporary Occupational Therapy (OT) and Physical Therapy (PT) telehealth flexibilities per SPECIAL BULLETIN COVID-19 #237 (which references SPECIAL BULLETIN COVID-19 #226 and SPECIAL BULLETIN COVID-19 #234) are scheduled to sunset on June 30, 2022 (previously set to expire March 31, 2022). All temporary policy flexibilities outlined in these bulletins remain in effect as of this publication date through June 30, 2022.
The State recognizes that there are unique circumstances for which telehealth delivery of OT and PT may be medically necessary. Beginning July 1, 2022, providers may request prior authorization (PA) for telehealth delivery of OT and PT services for Medicaid Direct beneficiaries ages 0-20 only as an EPSDT exception. EPSDT criteria can be found in NC Medicaid Clinical Coverage Policy 10A. Note: The EPSDT exception described applies only to beneficiaries enrolled in Medicaid Direct. For beneficiaries enrolled in a managed care plan, please refer to each applicable plan for guidance.
For details regarding the applicable OT and PT CPT codes that may be used for this telehealth exception, please see the PDF Document of SPECIAL BULLETIN COVID-19 #237 (pages 43-44). Here, you will also find information about:
- flexibilities that have been or are being incorporated into permanent policy.
- temporary flexibilities that will end on June 30, 2022.
- temporary flexibilities that will end at the end of the federal PHE (date TBD).
For provider convenience, below are the applicable OT and PT CPT codes scheduled to sunset on June 30, 2022, which will be available beginning July 1, 2022, through this EPSDT PA review. Services provided by telehealth require a GT modifier on the claim.
OCCUPATIONAL THERAPY
Evaluation Codes
- 97165 EVALUATION OF OCCUPATIONAL THERAPY, TYPICALLY 30 MINUTES
- 97166 EVALUATION OF OCCUPATIONAL THERAPY, TYPICALLY 45 MINUTES
- 97167 EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, TYPICALLY 60 MINUTES
- 97168 RE-EVALUATION OF OCCUPATIONAL THERAPY ESTABLISHED PLAN OF CARE, TYPICALLY 30 MINUTES
- 97750 PHYSICAL PERFORMANCE TEST OR MEASUREMENT WITH REPORT, EACH 15 MINUTES
Treatment Codes
- 92065 EXERCISES TO CORRECT EYEBALL MUSCLE IMBALANCES
- 92526 TREATMENT OF SWALLOWING AND/OR ORAL FEEDING FUNCTION (oral motor only)
- 97110 THERAPEUTIC EXERCISE TO DEVELOP STRENGTH, ENDURANCE, RANGE OF MOTION, AND FLEXIBILITY, EACH 15 MINUTES
- 97112 THERAPEUTIC PROCEDURE TO RE-EDUCATE BRAIN-TO-NERVE-TO-MUSCLE FUNCTION, EACH 15 MINUTES
- 97116 WALKING TRAINING TO 1 OR MORE AREAS, EACH 15 MINUTES
- 97530 THERAPEUTIC ACTIVITIES TO IMPROVE FUNCTION, WITH ONE-ON-ONE CONTACT BETWEEN PATIENT AND PROVIDER, EACH 15 MINUTES
- 97533 SENSORY TECHNIQUE TO ENHANCE PROCESSING AND ADAPTATION TO ENVIRONMENTAL DEMANDS, EACH 15 MINUTES
- 97535 SELF-CARE OR HOME MANAGEMENT TRAINING, EACH 15 MINUTES
- 97542 WHEELCHAIR MANAGEMENT, EACH 15 MINUTES
- 97763 ORTHOTIC(S)/PROSTHETIC(S) MANAGEMENT AND/OR TRAINING, UPPER EXTREMITY(IES), LOWER EXTREMITY(IES), AND/OR TRUNK, (SUBSEQUENT ORTHOTIC(S)/PROSTHETIC(S) ENCOUNTER, EACH 15 MINUTES)
PHYSICAL THERAPY
Evaluation Codes
- 97161 PT EVAL 20 MIN
- 97162 PT EVAL 30 MIN
- 97163 PT EVAL 45 MIN
- 97164 PT RE-EVAL
- 97750 PHYSICAL PERFORMANCE TEST
Treatment Codes
- 95992 CANALITH REPOSITIONING
- 97110 THERAPEUTIC PROCEDURE (THERAPEUTIC EXERCISE TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY).
- 97112 NEURO RE-EDUCATION (BALANCE, COORDINATION)
- 97116 GAIT TRAINING (INCLUDES CLIMBING STAIRS)
- 97530 THERAPEUTIC ACTIVITIES
- 97533 SENSORY TECHNIQUE TO ENHANCE PROCESSING AND ADAPTATION TO ENVIRONMENTAL DEMANDS, EACH 15 MINUTES
- 97535 SELF-CARE/ ADLS
- 97542 WC MANAGEMENT
- 97763 ORTHOTIC(S)/PROSTHETIC(S) MANAGEMENT AND/OR TRAINING, UPPER EXTREMITY(IES), LOWER EXTREMITY(IES), AND/OR TRUNK, (SUBSEQUENT ORTHOTIC(S)/PROSTHETIC(S) ENCOUNTER, EACH 15 MINUTES)
CONTACT
NCTracks Contact Center: 800-688-6696