How to Bill for Therapy Services

Enter one date of service per claim line (the From and To dates must be the same). Include
the designated provider modifier on all claims. After prior authorization is issued, billed
services must match the approved authorization. Be sure to include the Authorization Number on
all claims.

How to Know When Prior Authorization is Required

Some services always require prior authorization.  Recipients can receive, once per calendar year,
medically necessary service on 12 separate days (if age 21or older) or 24 separate days (if under
age 21) per discipline, before prior authorization is required. A day may include more than one
provider type and/or session before prior authorization is required. Evaluations/Reevaluations
do not count as one of these days and do not require prior authorization, however, they are limited as specified in Table.

Non-Covered Services

Non-covered therapy services include:

 Athletic training evaluation (codes 97005 and 97006)
 Unlisted modality (code 97039)
 Unlisted therapeutic procedure (code 97139)
 Community/work reintegration training (code 97537)
 Work hardening/conditioning (codes 97545 and 97546)
 Maintenance therapy for Lymphedma
 Services for non-speech-generating communication devices (codes 92605 and 92606)