Effective September 1, 2024, UnitedHealthcare is implementing new prior authorization requirements for a range of outpatient therapy services, including physical therapy. These changes are crucial for healthcare providers, particularly physical therapists, occupational therapists, speech therapists, and chiropractors who bill UnitedHealthcare Medicare Advantage plans. This article breaks down the new United Health Care New Coding Requirements For Physical Therapy to ensure your practice remains compliant and reimbursements are processed smoothly.
Key Changes to UnitedHealthcare Physical Therapy Coding in 2024
This update introduces mandatory prior authorization for specific outpatient therapy services delivered in multidisciplinary offices and outpatient hospital settings. It’s important to note that services provided in the home are excluded from these new requirements.
Prior Authorization Mandate
Prior authorization is now required for treatment plans for physical therapy, occupational therapy (OT), speech therapy (ST), and Medicare-covered chiropractic services (when billed with the AT-modifier). This means that while the initial evaluation does not require pre-approval, the subsequent treatment plan and any continuation of care beyond the initial plan will need to be authorized by UnitedHealthcare.
Affected Services and Settings
These new coding requirements apply specifically to services provided in:
- Multidisciplinary Offices: These can be single facilities offering multiple therapy disciplines or individual practices specializing in one discipline but operating within a larger network or billing structure considered multidisciplinary by UnitedHealthcare.
- Outpatient Hospital Settings: This includes both on-campus and off-campus locations.
Place of Service Codes Requiring Authorization
To further clarify, prior authorization is mandatory for the following Place of Service (POS) codes:
- 11: Office
- 19: Off-Campus Outpatient Hospital
- 22: On-Campus Outpatient Hospital
- 24: Ambulatory Surgical Center
- 49: Independent Clinic
- 62: Comprehensive Outpatient Rehabilitation Facility
These requirements are applicable nationwide for UnitedHealthcare Medicare Advantage plans, with the exception of Dual Complete Special Needs Plans (SNP). It’s also worth noting that existing prior authorization protocols in Arkansas, Georgia, South Carolina, and New Jersey for outpatient therapies are being expanded to include Medicare-covered chiropractic services under these new guidelines.
Understanding the Prior Authorization Process for Physical Therapy
Navigating the prior authorization process is essential to avoid claim denials and ensure timely patient care. Here’s a breakdown of what you need to know:
Initial Evaluation vs. Treatment Plan
Crucially, prior authorization is not required for the initial physical therapy evaluation. You can conduct the initial assessment without pre-approval to determine the patient’s needs. However, to proceed with treatment, you must obtain prior authorization for the proposed treatment plan. This plan should detail the number of visits required and be supported by the initial evaluation results.
Healthcare providers are required to submit both the initial evaluation results and the proposed plan of care using an outpatient assessment form. After the initial authorized treatment plan is completed, any requests for additional visits will also necessitate a new prior authorization submission.
Medical Necessity Review
UnitedHealthcare utilizes a rigorous medical necessity review process for all prior authorization requests. This process ensures that the requested services are clinically appropriate and align with established guidelines. The review process leverages several key resources:
- CMS Chapter 15 Criteria: These federal guidelines for Medicare services serve as a foundational benchmark for medical necessity.
- Applicable LCDs (Local Coverage Determinations): These are regional guidelines that further define coverage parameters based on specific geographic areas.
- InterQual® Criteria: This widely recognized, evidence-based clinical decision support tool provides objective benchmarks for medical necessity.
Medical necessity reviews are conducted by licensed medical professionals, including physical therapists, occupational therapists, and speech-language pathologists. Both the provider and the patient will receive notification regarding the determination of medical necessity.
Impacted Procedure Codes and Plans under UnitedHealthcare’s New Policy
It’s vital to identify which specific procedure codes and UnitedHealthcare plans are affected by these new prior authorization rules.
Outpatient Therapy Codes Requiring Prior Authorization
The following outpatient therapy procedure codes now require prior authorization:
- 92507, 92508, 92526, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97164, 97168, 97530, 97533, 97535, 97537, 97542, 97545, 97546, 97750, 97755, 97760, 97761, 97799, G0283
Note: This comprehensive list includes codes for physical therapy, occupational therapy, and speech therapy services.
Chiropractic Service Codes (Medicare-Covered)
Medicare-covered chiropractic services also fall under the new prior authorization mandate when billed with the AT-modifier, specifically for the following codes:
- 98940, 98941, 98942 (with AT-modifier)
UnitedHealthcare Medicare Advantage Plans Affected
These changes impact a wide range of UnitedHealthcare Medicare Advantage plans, including:
- Medicare Individual (including Chronic SNPs)
- Medicare Group Retiree
- UHCWest Medicare plans in Nevada, Oregon, Washington, and Texas
- UHCWest Medicare plans in Colorado (starting January 1, 2025)
Plans Excluded: It’s important to note that certain plans are excluded from these new requirements. These include: UnitedHealthcare® Dual Complete plans, UnitedHealthcare® Nursing Home and UnitedHealthcare® Assisted Living Plans, Erickson Advantage, Preferred Care Network and Preferred Care Partners of Florida, UHCWest (California, Arizona), OptumCare, WellMed, Peoples Health Plan, and Rocky Mountain Medicare Advantage plans.
How to Submit Prior Authorization Requests to UnitedHealthcare
UnitedHealthcare has streamlined the prior authorization process through their Provider Portal. Here’s a step-by-step guide to submitting your requests online:
- Access the UnitedHealthcare Provider Portal: Go to UHCprovider.com and click “Sign In” in the top-right corner.
- Log In: Enter your One Healthcare ID and password.
- Navigate to Prior Authorizations: In the menu, select “Prior Authorizations.”
- Start a New Request: Scroll down to “Create a new prior authorization submission,” click “Select prior authorization type for submission” and then select “Physical Health.”
- Select Plan Type: Next, click “Select plan type,” choose “Medicare,” and click “Continue.”
- Enter Information and Submit: Enter all required information related to the patient, service, and treatment plan. Submit the completed request.
Important Deadline: Ensure you submit your prior authorization request promptly. UnitedHealthcare states that if a request is not received within 10 days after the service commences, the claim may be denied, and providers will not be able to balance bill the member.
Resources and Further Information
For more detailed information and resources, refer to the following documents and websites:
- CMS Chapter 15: Link to PDF of CMS Chapter 15 criteria – Provides the foundational medical necessity criteria.
- UnitedHealthcare Medicare Advantage Prior Authorization Requirements: Link to PDF of UnitedHealthcare 2024 Medicare Advantage Prior Authorization Requirements – Outlines UnitedHealthcare’s specific guidelines for prior authorization.
- Skilled Nursing Facility, Rehabilitation and Long-Term – Medicare Advantage Coverage Summary: Link to PDF of UnitedHealthcare Medicare Advantage Skilled Nursing Facility, Rehabilitation,and Long-Term Acute Care Hospitalization – Offers a broader overview of Medicare Advantage coverage policies.
- UnitedHealthcare Prior Authorization and Notification web page: Link to UnitedHealthcare Prior Authorization and Notification web page – A central hub for information on prior authorization and notification processes.
By understanding and adhering to these new United Health Care new coding requirements for physical therapy, providers can ensure seamless service delivery and appropriate reimbursement for their services under UnitedHealthcare Medicare Advantage plans. Staying informed and proactive is key to navigating these changes effectively.
