Physical, Occupational, & Massage Therapy

Authorization

For State Fund claims
Standard Outpatient and Work Conditioning Services - Action Required
# of total visits on claim PT Only or OT Only PT/OT Combined
Visits 1 - 12No authorization needed.If less than 12 visits for both disciplines, no authorization needed.
Visits 13 - 24 Fax Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request (F245‑417‑000) form for authorization.

If visits are between 13 - 24 for either discipline, fax Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request (F245‑417‑000) form for authorization.

Visits beyond 24Request Utilization Review from Qualis directly. Claim manager will authorize or deny.If greater than 24 visits for either discipline, request Utilization Review from Qualis directly. Claim manager will authorize or deny.
  1. 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.
  2. Physical and occupational therapy visits accumulate separately.
  3. If Work Conditioning is provided by both PT and OT and greater than 24 visits have previously occurred for either therapy discipline, utilization review is required. If Work Conditioning is denied, L&I will allow up to 12 visits for the discipline that hasn't reached 12 visits.
Work Hardening Action Required
All services Request authorization from claim manager. Claim manager will authorize or deny.
Massage (MT) Action Required
  First 6 visits 6th - 12th visit Over 12 visits
Massage therapy No authorization needed Complete form and fax Contact claim manager 

 

For Self-Insured claims:

Contact the self-insured employer's claim manager.

Who may perform physical, occupational, or massage therapy?

Therapist type: Physical Therapy (PT) Occupational Therapy (OT) Massage Therapy (MT)
Must be: Licensed Physical Therapist Licensed Occupational Therapist Licensed Massage Practitioner (LMP).
Or:

PT assistant under the direction of a licensed PT

Athletic trainer under the direction of a licensed PT

OT assistant under the direction of a licensed OT N/A.

Who else may perform these services?

  • Medical or Osteopathic physicians who are board qualified or board certified in medicine and rehabilitation.
  • Attending physicians who are not board qualified or board certified in physical medicine and rehabilitation. Special payment policies apply. See the Physical Medicine chapter in the Payment Policies.

Can I get paid for services performed by other personnel?

No. L&I will not pay providers for services provided by

  • exercise physiologists,
  • kinesiologists,
  • students,
  • aides, and
  • other unlicensed personnel.

Do I need to obtain authorization for the first 12 (PT/OT) or 6 (MT) visits on a claim?

No, but the services need to be ordered by the worker's attending provider.

What needs to be done to treat beyond the first 12 (PT/OT) or 6 (MT) visits on a claim?

You need to do the following:

  1. Document functional improvement in the worker's condition.
  2. Document continued referral from the attending provider.
  3. Obtain authorization.

Note: Further coverage may be denied by the claim manager if documentation is not available or authorization is not obtained.

What additional guidelines exist for work conditioning?

  • Frequency: At least three times per week and no more than 5 times per week.
  • Duration: No more than 8 weeks for one set. One set equals up to 20 visits.
    • An additional 10 visits may be approved upon review of progress.
  • Plan of Care: Goals are related to:
    • Increasing physical capacities, and
    • Return to work function, and
    • Establishing a home program allowing the worker to progress and/or maintain function after discharge.
  • Documentation: Besides standard documentation, it must include return to work capacities, which may include lifting, carrying, pushing, pulling, sitting, standing, and walking tolerances.
  • Treatment: May be 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 allowed on the same date of service.
    • Billing reflects active treatment. Examples include CPT® 97110, 97112, 97530, 97535, and 97537.

 

End of main content, page footer follows.

Access Washington official state portal

  © Washington State Dept. of Labor & Industries. Use of this site is subject to the laws of the state of Washington.

Help us improve