Authorization

Standard outpatient therapy and work conditioning services

# of total visits on claim PT only or OT only program PT and OT program
Visits 1 - 12 No authorization needed If less than 12 visits for both disciplines, no authorization needed
Visits 13 - 24 Fax the Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request (F245‑417‑000) form  If visits are between 13 - 24 for either discipline, fax the Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request (F245‑417‑000) form

Visits beyond 24 Request Utilization Review from Comagine Health directly If greater than 24 visits for either discipline, request Utilization Review from Comagine Health directly.
  • Visit counts are the total number of visits per claim.
  • New referrals, restart of therapy following surgery, or treatment of new conditions on the same claim do not start again at visit 1.
  • Physical and occupational therapy visits accumulate separately.

Work hardening services

Work Hardening Request authorization from claim manager

Massage therapy services

Massage First 6 visits Visits 6 – 12 Over 12 visits
Massage therapy No authorization needed Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request (F245‑417‑000) form Contact claim manager

For workers covered under Self-Insured Employer: Contact the self-insured employer or its representative directly.

L&I may reimburse for the following provider types for physical medicine services:

Therapist type Physical therapy (PT) Occupational therapy (OT) Massage therapy
Must be: Licensed PT Licensed OT Licensed Massage Therapist
Or: Under the direction/supervision of a: licensed PT:
PT student
PT assistant
Athletic trainer
Under the direction/supervision of a licensed OT:
OT student
OT assistant

N/A

Other covered providers of physical medicine services

  1. Medical or osteopathic physicians who are board qualified or board certified in physical medicine and rehabilitation.
  2. For attending providers, special payment policies may apply. These policies apply when these providers are not board qualified or certified in physical medicine and rehabilitation. See the Physical Medicine chapter in our payment policies section.

L&I will not pay for services provided by exercise physiologists, kinesiologists, aides and other unlicensed personnel.

Work conditioning guidelines

L&I covers work conditioning under Payment Policy Chapter 25 and with these additional guidelines:

  • Occurs 3-5 times per week and usually up to 20 visits.
  • Treatment goals relate to:
    • Increasing physical capacities.
    • Return to work function.
    • Establishing a home program allowing the worker to progress and/or maintain function after discharge.
  • Documentation includes return to work capacities such as lifting, carrying, pushing, pulling, sitting, standing, and walking tolerances.
  • Provided by a single therapy discipline (PT or OT) or combination of both (PT and OT).
    PT and OT visits accumulate separately and both are payable on the same day of service.
  • Billing reflects active treatment. Examples include CPT® 97110, 97112, 97530, 97535, and 97537.

Learn about the differences between work conditioning and work hardening.

Documentation

Send in your required medical records

  • Workers covered by L&I: Fax to 360-902-4567. Make sure the claim number is on every page.
  • Workers covered by self-insured employer: Send directly to employer.

Records to send

Initial evaluations

Daily chart notes and flow-sheets

Progress reports

Discharge summaries

    Daily chart notes and flow-sheets

    • Use the SOAPER format: Subjective, Objective, Assessment, Plan, Employment, Recovery.
    • Make sure your records verify the level, type and extent of services provided to the individual.
    • Include the duration of treatment for each timed code that billed.
    • Document the specific intervention performed, the area treated, the frequency and intensity (if appropriate), and the intended purpose for each service. Simply documenting the procedure code is insufficient and may result in denial of the bill or recoupment of payment.
    • As the person performing the services, you must include your name, title, and signature on all records submitted.
    • Submit all documentation to support your billing.

    Progress reports

    • For massage therapists, send after 6 treatment visits or 1 month, whichever comes first.
    • For physical therapists and occupational therapists:
      • Send after 12 treatment visits or 1 month, whichever comes first to the attending provider and insurer.
      • Use the Physical Medicine Progress Report (F245-453-000).
        Follow the Instructions for the Physical Medicine Progress Report (PMPR).
        • Physical and occupational therapists who provide outpatient therapy based on WAC 296-23-220 and WAC 296-23-230 must use the PMPR. This also includes work conditioning programs unless your work conditioning progress report meets work hardening program requirements with a comprehensive summary of the individual's capacity level.
        • The PMPR is not required for: Home health, inpatient rehabilitation, out-of-state providers, consulting therapists, or work hardening programs. In addition, the form is not required for a standard outpatient therapy initial evaluation or discharge summary.

    PMPR questions?

    View answers to frequently asked questions.
    Please contact us at therapy@Lni.wa.gov or call 360-902-9115.

    What if the worker is not participating or progressing in treatment?

    Not participating

    • Document cancellations and missed appointments.
    • Contact the claim manager if the individual is not participating as expected.

    Not progressing

    • Document the worker's progress in chart notes and progress reports.
    • Reach out to the attending provider to determine if other services such as behavioral health interventions or activity coaching would help recovery.
    • If the care is neither curative nor rehabilitative, plan for discharge and finalize their home program.

    Note: L&I does not cover palliative care. Providing palliative care may prolong the claim and contribute to the possibility of long-term disability for the individual. Research shows that it is in the best interest of the individual to stop medical treatment once functional improvement has ended.

    Billing & Payment

    Payment

    Physical and occupational therapy

    Includes standard outpatient therapy and work conditioning

    Daily maximum Effective July 1, 2021: $136.74
    Covered billing codes Applies to CPT ™ codes 64550, 95831-95852, 95992, 97010-97799, and HCPCS code G0283

    Massage therapy

    Daily maximum Effective July 1, 2021: $102.56
    Covered billing code 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.

    Daily maximum: L&I will pay for a maximum of 1 each outpatient physical therapy, occupational therapy, or massage therapy visit per day.

    • L&I will only pay for 1 therapist of the same therapy discipline per day.
    • If 2 different types of therapists provide services on the same day, the daily maximum applies once for each provider type per claim.

    For more information, refer to the Professional Services Payment Policies Physical Medicine Chapter.

    Billing

    Group therapy

    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.

    Modalities and untimed services

    Supervised modalities and untimed therapeutic procedures are limited to 1 unit per day.

    Phone calls

    Telephone calls are payable under certain conditions. See Professional Services Payment Policies Evaluation and Management Services Chapter for coverage details including documentation requirements and billing codes.

    Supplies/materials

    We only pay for services and supplies that are medically necessary and prescribed by the attending provider for treatment of a covered condition. Contact the Provider Hotline at PHL@lni.wa.gov, or 1-800-848-0811.

    Telehealth

    See Professional Services Payment Policies Updates and Corrections Chapter 25 for our coverage details for services provided by telehealth.

    Work conditioning

    Bill your services under the most appropriate procedure codes. Examples include CPT® 97110, 97112, 97530, 97535, and 97537. Only approved work hardening programs are paid under CPT™ 97545 and 97546.

    Functional Capacity Evaluations

    Functional Capacity Evaluations are a service to evaluate physical abilities to:

    • Perform work activities.
    • Help plan for return to work.
    • Guide recommendations about the type or length of treatment needed for recovery and return to work.

    Workers can learn more about this service in our publication, Understanding Your Functional Capacity Evaluation (F245-416-000).

    Who may perform this service?

    • Occupational therapists.
    • Physical therapists.
    • Medical or osteopathic physicians who are board qualified or board certified in physical medicine and rehabilitation.

    Procedure codes for this service

    • 1045M – Standard FCE
    • 1098M – Supplemental FCE

    Resources for FCE providers

    Resources for vocational providers (VRCs)

    Resources

    How do I get notified of policy updates?

    Sign up for L&I's Physical Medicine Updates email updates for announcements.

      Phone numbers

      First stop: Automated claim information line

      1-800-831-5227
      Monday–Friday 6 a.m. through 7 p.m. PST

      Have your provider account number ready when you call. You can get the following information:

      • Claim status
      • Claim manager names and phone numbers
      • Authorization and Utilization Review status
      • Bill payment status
      • Physical, occupational and massage therapy visit counts

      Provider hotline

      1-800-848-0811

      PHL@lni.wa.gov

      Web resources

      Activity Coaching/Progressive Goal Attainment Program
      Behavioral Health Interventions
      Claim and Account Center
      Comagine Health
      Condition and Treatment Index
      Conservative Care Evidence Summary: Options for Documenting Functional Improvement
      Conservative Care Evidence Summary: Reducing Disability
      Differences between work hardening and work conditioning
      Fee schedules and payment policies (MARFS)
      Find a Doctor
      Industrial Insurance Chiropractic Advisory Committee (IICAC)
      Job modifications
      Physical Medicine Project
      Physical & Occupational Therapy Utilization Review
      Pre-job accommodations
      Provider Hotline Authorizations
      Utilization Review
      Vendor Services Lookup
      Work hardening
      Work Rehabilitation Guideline

      Forms and publications

      Functional Capacity Evaluation Summary (F245-434-000)
      Physical Medicine - Best practices quick reference guide (F245-464-000)
      Physical Medicine Progress Report (F245-453-000)
      Physical Medicine Progress Report Form Instructions
      Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request (F245-417-000)
      Weights of Common Items (F245-415-000)
      Worker Travel Reimbursement (F245-145-000)

      Rules

      WAC 296-20: Medical Aid Rules (full chapter)
      WAC 296-20-010(7): General information
      WAC 296-20-01002: Definitions
      WAC 296-20-015: Who may treat
      WAC 296-20-02010: Review of health services providers
      WAC 296-20-024: Utilization management
      WAC 296-20-030: Treatment not requiring authorization for accepted conditions
      WAC 296-20-03001: Treatment requiring authorization
      WAC 296-20-03002: Treatment not authorized
      WAC 296-20-06101: What reports are health care providers required to submit to the insurer?
      WAC 296-21-290: Physical Medicine
      WAC 296-23-220: Physical therapy rules
      WAC 296-23-230: Occupational therapy rules
      WAC 296-23-250: Massage therapy rules