Standard outpatient therapy
# 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 rehabilitation services
Work Rehabilitation | Treatment requires |
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
- Medical or osteopathic physicians who are board qualified or board certified in physical medicine and rehabilitation.
- 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.
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.
- The PMPR is not required for: Home health, inpatient rehabilitation, out-of-state providers, consulting therapists, or work rehabilitation programs. In addition, the form is not required for a standard outpatient therapy initial evaluation or discharge summary.
PMPR questions?
- Please contact us at therapy@Lni.wa.gov.
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.
Payment
Physical and occupational standard outpatient therapy
Daily maximum | Effective July 1, 2023: $143.66 |
Covered billing codes | Applies to CPT ™ codes 97161-97168, 97010-97799, and 95992 |
Massage therapy
Daily maximum | Effective July 1, 2023: $107.75 |
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, Chapter 25 - Physical Medicine Services.
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 Physical Medicine Chapter for our coverage details for services provided by telehealth.
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
- FCE Summary Form (F245-434-000) – This form is required for workers covered under L&I and when services are provided in Washington.
- Standards for FCE Clinics
- FCE Evaluation Elements – minimum testing elements
- FCE Definitions
- Physical Medicine Payment Policies
Resources for vocational providers (VRCs)
- Standards for VRCs when worker is covered by L&I
- Find an FCE provider using the Vendor Services Lookup Tool
- AP Questionnaire after an FCE
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
- Authorization and billing questions
- Obtain PT/OT/MT visit counts by selecting option 2
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
- Fee schedules and payment policies (MARFS)
- Find a Doctor
- Industrial Insurance Chiropractic Advisory Committee (IICAC)
- Job modifications
- Physical & Occupational Therapy Utilization Review
- Pre-job accommodations
- Provider Hotline Authorizations
- Utilization Review
- Vendor Services Lookup
- Work Rehabilitation 2024
- Work Rehabilitation Guideline
Forms and publications
- Functional Capacity Evaluation Summary (F245-434-000)
- Outpatient Services Referral Guide for Physical and Occupational Therapists (F245-494-000)
- Physical Medicine - Best practices quick reference guide
- Physical Medicine Progress Report (F245-453-000)
- Physical Medicine Progress Report Form Instructions
- Physical/Occupational Therapy Referral Checklist for Attending Providers (F245-495-000)
- 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