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Billing & Payment
This page has information about billing, payments, and answers to common questions for outpatient services.
What is the maximum payment?
L&I will pay for a maximum of one each physical therapy (PT), occupational therapy (OT), or massage therapy (MT) visit per day.
The maximum payment for all services by any provider type, on one day, is generally referred to as the daily maximum. The daily maximum applies to CPT™ codes 64550, 95831-95852, 97001-97799, and HCPCS code G0283.
The daily maximum doesn't limit payment for the following services:
- Performance-based physical capacities evaluations.
- Work hardening programs.
- Pain management programs.
- Job, home, or vehicle modification consultations.
- Work evaluations.
What codes can a PT/OT bill for evaluation and treatment services?
The table below lists the most commonly used codes for PT/OT providers. For detailed information about those codes, refer to the Physical Medicine and Biofeedback sections of the Professional Services Payment Policies (2,640 KB PDF / 8 min).
Get Help Downloading Files (files open in a new window).You may contact the Provider Hotline 1-800-848-0811 to verify if other codes are payable.
| Physical and Occupational Therapy | |
|---|---|
| Daily maximum | Effective July 1, 2008$118.07. |
| Most commonly used codes | |
| Physical medicine | CPT ™ 97001 - 97799. CPT ™ 97150 - Bill 1 unit for each patient participating in group therapy.Therapist must be in constant attendance during group therapy. HCPCS codes for miscellaneous materials and supplies. |
| TENS fitting | CPT ™ 64550 - L&I allows this code only 1 time per claim. |
| Job modification / Pre-job accommodation | 0389R - Consultation. 0391R - Travel/wait. 0392R - Mileage. 0393R - Ferry charges. Requires prior authorization by claim manager. |
| Work evaluation services | 0390R - Consultation. 0391R - Travel/wait. 0392R - Mileage. 0393R - Ferry charges. These codes are paid only when provided as part of a vocational evaluation. Requires prior authorization by claim manager. |
| Stand alone or provisional job analysis | 0378R - Paid only when provided to assist a voc counselor in the completion of a job analysis for a voc referral. Requires prior authorization by claim manager. |
| Performance-based physical capacity evaluation | 1045M - Payable only to physicians who are board qualified or certified in physical medicine and rehab and to PTs/OTs. Does not require prior authorization. |
| Work hardening | 1001M and CPT ™ 97545 - 97546 - Payable only to L&I approved work hardening providers. Requires prior authorization by claim manager. See the Work hardening site for more information. |
| Non-covered billing codes | |
| CPT ™ codes: 97005, 97006, 97033, 97781, | |
| Massage Therapy | |
|---|---|
| Daily maximum | Effective July 1, 2008$88.55. |
| Covered billing code | CPT ™ 97124 - used for all forms of massage therapy, regardless of the technique used. No other codes are reimbursed. Bill 1 unit of CPT™ 97124 for each 15 minutes of massage therapy. |
Answers to common questions
What if the patient sees 2 types of therapist on the same day?
If 2 types of therapist provide services on the same day, the daily maximum applies once for each provider type per claim.
Example: A worker receives massage therapy from a licensed massage practitioner and also receives treatment from a physical therapy provider on the same day. Both are eligible for payment up to the daily maximum.
How do I bill for modalities and untimed services?
Supervised modalities and therapeutic procedures that do not list a specific time increment in their description, are limited to 1 unit per day.
CPT ™ codes: 97001, 97002, 97003, 97004, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97150.
Does L&I or self-insurer pay PT/OT/MT providers for phone conferences?
Yes. Telephone calls are payable under certain conditions. See L&I's payment policies for coverage details including documentation requirements and billing codes.
Can a PT/OT provider be paid for the review of job analyses?
No. The review of job analyses is payable only to specific doctors.
Can I bill for services performed by another licensed therapist?
No. A therapist can bill for services provided by an assistant, but not for services provided by another therapist. Each therapist must establish a provider account number with L&I.
Can I get paid for all supplies/materials?
No. L&I only pays for services and supplies that are medically necessary and prescribed by an approved provider for treatment of a covered condition. Contact the Provider Hotline at 1-800-848-0811.
How should PT/OT providers bill for work conditioning?
Work conditioning services should be billed using the PT and OT billing codes (97001-97799 excluding 97545 and 97546).
How should PT/OT providers bill for services not provided as one-on-one?
Group therapy services are defined as services provided simultaneously by a therapist (as opposed to the therapist giving full attention to a single patient). The therapist must be in constant attendance during group therapy. Bill only 1 unit of CPT™ 97150 for each patient participating in group therapy.
Time spent by patients who are independently exercising (no therapist or assistant in constant attendance) is not billable.
