Physical, Occupational, & Massage Therapy

Who can Treat?
Documenting
Billing &
Payment
Treatment
Issues
Resources

Who can treat?

The information below covers who may treat, the procedures and the authorization requirements for outpatient therapy services.

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	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.

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Can I get paid for services performed by other personnel?

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

Exercise physiologists,
Kinesiologists,
Athletic trainers,
Students,
Aides, and
Other unlicensed personnel.

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

No, but the services need to be ordered by the injured worker's attending doctor or their physician assistant or nurse practitioner.

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

You need to:

Document improvement in the worker's condition,
Document continued referral from the attending physician, and
Obtain authorization.

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

How do I obtain authorization for additional (outpatient) visits?

For State Fund claims: Effective July 1, 2007

Standard outpatient and work conditioning services - Action required
# of visits	PT only or OT only	PT/OT combined
Visits 1 - 12	No authorization needed.	If less than 12 visits for both disciplines, no authorization needed.
Visits 13 - 24	Fax OT/PT Treatment Authorization Fax Request (F248‑055‑000) form for authorization.	If visits are between 13 - 24 for either discipline, fax OT/PT Treatment Authorization Fax Request (F248‑055‑000) form for authorization.
Visits beyond 24	Request 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.
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. 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
Visits beyond first 6	Use the Massage Practitioner Treatment Authorization Fax Request (F248‑357‑000) form, or make a referral to the claim manager using the Provider Hotline 1‑800‑848‑0811.

For Self-Insured claims:

Contact the self-insured employer's claim manager.

Documenting

Below you will find the documents and reports required by L&I.

What records do I need to send L&I or self-insurer?

PT, OT and LMPs are required to submit legible chart notes and progress reports. Include any exercise or flow sheets that are referenced in your chart notes.

What kind of information should be included in daily chart notes?

Use the SOAP format (subjective, objective, assessment, plan). Records must verify the level, type and extent of services provided to the injured worker. Report the duration of treatment for each timed code that is billed.

When are progress reports required?

For PTs or OTs:

Submit your progress reports after 12 treatment visits or 1 month (whichever comes first). Send copies to:

The attending doctor and
L&I or self-insurer.

For LMPs:

Submit your progress reports after 6 treatment visits or 1 month (whichever comes first). Send copies to:

The attending doctor and
L&I or self-insurer.

Does L&I or self-insurer have a standard format for progress reports?

For PTs and OTs: Yes.

Use the Physical Therapy /Occupational Therapy Progress Report to Claim Managers form (F245-059-000). This is used to document the injured worker's progress toward clearly stated clinical goals and return-to-work objectives.

For LMPs: No.

Is the Physical Therapy /Occupational Therapy Progress Report to Claim Managers form mandatory?

No. It's not required but is strongly encouraged.

What needs to be included on my progress report if I don't use the form above?

Put the patient's name and claim number in upper right-hand corner of each page.
The diagnosis/condition that is being treated.
The dates of service covered by the report.
Total number of visits to date for this condition.
Number of cancelled and no-show appointments.
Name of referring physician and date of latest referral.
Objective findings including baseline, last progress report (if applicable), current status and objective measurable goals.
Your estimate of the injured worker's potential to physically perform the job of injury.
Identify alternative job goals if the injured worker is not returning to the job of injury.
The injured worker's level of the participation in this plan of care.
Whether or not the injured worker is making meaningful, functional progress in treatment.
A description of the treatment plan and goals for the next set of treatments, including frequency and duration.
An estimate of when the injured worker will be discharged from therapy.
Your signature and the date signed.
Your clinic name, city and phone number.

Who is required to sign chart notes and progress report?

The person performing the services must include their name, title and signature on all records submitted.

How does L&I prefer to receive claim correspondences (medical records)?

L&I prefers to receive this information by fax.

For State Fund claims:

For chart notes, reports and letters (not bills):

Fax to any of the following numbers:
360-902-4292 360-902-4565 360-902-4566 360-902-4567	360-902-5230 360-902-6100 360-902-6252 360-902-6460
OR

Mail to:

Department of Labor & Industries
PO Box 44291
Olympia, WA 98504-4291

Use plain, white, 8.5 x 11 inch paper. One side only. No partial sheets of paper.
Avoid the following:

Colored paper,
Carbonless paper,
Highlighter markings,
Shaded areas, or
Dark or black borders or logos, especially on the top border.

For self-insured claims:

Send the bills and correspondence to the self-insured employer or their representative.

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.

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You may contact the Provider Hotline 800-848-0811 to verify if other codes are payable.

Physical and Occupational Therapy
Daily maximum	Effective July 1, 2012$119.01.
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.
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, 2012$89.26.
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 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.

Phone numbers
Provider Hotline	800-848-0811
Therapy Services Coordinator	360-902-4480
Interactive Voice Response Message System (IVR) Use your provider account number to access information on: The status of State Fund claims. Allowed/denied diagnosis and procedure codes. Current bill status. Name and phone of claim manager. IVR is available weekdays 6:00 a.m. - 7:00 p.m.	800-831-5227

Labor & Industries (L&I), Washington State

For Medical Providers