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
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

Discharge summaries

Progress reports sent to the attending doctor and insurer:

  • For PTs and OTs,
    • Send after 12 treatment visits or 1 month, whichever comes first.
    • Use the Physical Medicine Progress Report Form (F245-453-000)
      • Follow the Instructions for the Physical Medicine Progress Report Form.
      • 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. 
  • For MTs, send after 6 treatment visits or 1 month, whichever comes first.

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.

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.
  • 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, 2019: $126.94
Covered billing codes Applies to CPT ™ codes 64550, 95831-95852, 95992, 97010-97799, and HCPCS code G0283

Massage therapy

Daily maximum Effective July 1, 2019: $95.21
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 therapist 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 1-800-848-0811.

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

Physical and Occupational Therapists have a new tool to help measure progress of standard outpatient therapy services. L&I's Physical Medicine Progress Report (PMPR) form F245-453-000 is available to use when treating patients covered under Washington State's workers' compensation.

In addition, see our L&I Physical Medicine Best Practice quick reference card.

Why are you making this change?
This form creates a standard to measure baseline and progress over the course of treatment. It also promotes best practices among physical and occupational therapists.

When will use of the form be required?
The Physical Medicine Progress Report (PMPR) form is required as of Oct. 1, 2020.

Who is required to use the form?
Physical and Occupational Therapists who provide standard 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.

When is the form not required?
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.

My current progress report form has the same information as the new PMPR form. Can I just submit my progress report?
The new form has several improvements that help locate essential information on the form and features a unique document identifier to more easily find it in the claim file.

Will I be reimbursed for filling out the PMPR form?
No. A progress report has always been required, and it has not been a billable document. The use of the PMPR replaces your current progress report. Because it is a standardization of an already existing process, it is not reimbursable.

Are attending providers required to sign off on the PMPR form?
No, but a signature from the attending provider (AP) indicates they are engaged with the patient’s care and aware of further treatment recommendations. L&I expects APs to review progress reports monthly. A signed PMPR form indicates an active referral and may facilitate approval for additional care.

Do I send the PMPR form with my utilization review request for further treatment?
Yes. As of Oct. 1, 2020, submit your most recent PMPR when requesting utilization review with Comagine Health for standard outpatient therapy.

Will the PMPR be integrated into Electronic Medical Record (EMR) systems?
The decision to integrate the form within your clinic’s EMR rests with your clinic. L&I technical staff are available to support EMR system technical groups during their integration process.

Is there an instruction sheet for the PMPR form?
Yes. See our PMPR Instruction sheet.

Do I need to fill out Section 2 with my patient? 
We recognize you may not wish to utilize the visit time to fully complete Section 2 with your patient. We encourage you to ask your patient to answer the questions in Section 2 e and f during their session.

Do I have to send this form to L&I and the attending provider?
Yes. This requirement does not change with the new form.

Can I sign the form using an electronic signature?
Yes, our payment policy allows for electronic signatures and signature stamps.

Instead of faxing the form, is there another way to submit it?
While faxing the PMPR to 360-902-4567 is the preferred method, it may also be mailed to: PO Box 44291, Olympia WA 98504-4291.

PMPR questions?
Please contact us at therapy@lni.wa.gov or call 360-902-9115.

How do I get notified of policy updates?

  • Sign up for L&I's Medical Provider News 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

    • Authorization and Billing Questions
    • Obtain PT/OT/MT visit counts by selecting option 2

    Web resources

    Fee schedules and payment policies (MARFS)
    Physical & Occupational Therapy Utilization Review
    Work hardening
    Job modifications
    Pre-job accommodations
    Differences between work hardening and work conditioning
    Condition and Treatment Index
    Advisory Committee Resources
    Physical Medicine Project
    Provider Hotline Authorizations
    Utilization Review
    Comagine Health
    Vendor Services Lookup
    Find a Doctor
    Claim and Account Center

    Forms and publications

    Functional Capacity Evaluation Summary (F245-434-000)
    Physical/Occupational/Massage Therapy Provider Hotline Service Authorization Request (F245-417-000)
    Physical Medicine Progress Report (F245-453-000)
    Physical Medicine Progress Report Form Instructions
    L&I Physical Medicine - Best practices quick reference guide
     (F245-464-000)
    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

    Telerehab Resources

    Telerehab services may continue until June 30, 2021.

    Temporary policies for Telerehab and Telerehab Work Hardening

    Highlights:

    • For outpatient physical, occupational, speech therapy evaluation, treatment, and re-evaluations. This includes work conditioning.
    • For services that can be done with verbal or visual components (no hands-on).
    • Still need to meet our existing coverage criteria.
    • Continue to send in your required medical documentation and progress notes.
    • These visits count toward your authorized visits and are considered the same as and paid consistently as in-person visits.
    • Bill for your services in the same manner as your in-person visits.  When the client is participating from home, use 12 as your place of service except for providers billing on UB-04 forms.
    • Not limited to 1 time per week.
    • For Telerehab Work Hardening:
      • If you are unable to provide at least 4 hours of services per day, you may reduce the program to 2 hours per day.
      • If your program may exceed 30 visits while providing telehealth services and the client is progressing toward their return-to-work goal, you may request an extension. To do so, contact the claim manager before your current authorization period has ended. Authorization extension will be considered on a case-by-case basis.

    Besides face-to-face visits, other types of interactions may be covered.

    Telehealth/rehab

    Telehealth/rehab provides real time, two-way video with audio communication.

    Purpose

    • Interaction between the provider and worker
    • For delivery of physical medicine services that require visual assessment and feedback to the worker

    Policy

    Additional information

    • Chapter 10: Teleconsultations and other telehealth services

    Telephone calls

    Telephone calls provide audio-only communication over telephone.

    Purpose

    • Communication with workers
    • For discussing or coordinating care or treatment across providers

    Policy

    • Chapter 10: Case management services – telephone calls
    • Payable for treating physical therapists, occupational therapists, speech language pathologists, and massage therapists

    Online communication

    Online communication is provided through secure email/portal.

    Purpose

    • Communication with workers
    • For responding to messages, coordinating care, treatment, or return to work activities across providers

    Policy

    • Chapter 10: Case management services – online communication and consultations