Reminder: NIA and Outpatient Physical Medicine Services (PT, OT, ST)
Date: 08/07/20
Effective June 1, 2020, outpatient physical medicine services (physical therapy, occupational therapy and speech therapy) are no longer managed through a post-service review process for Sunflower Health Plan
- PRIOR AUTHORIZATION REQUIRED: Sunflower remains committed to ensuring that physical medicine services provided to our members are consistent with nationally recognized clinical guidelines. Therefore, as of June 1, 2020, prior authorization of outpatient physical medicine services is required for Sunflower Health Plan membership. The utilization management of these services will continue to be managed by NIA.
- Under terms of the agreement between Sunflower Health Plan and NIA, Sunflower will oversee the NIA Physical Medicine Outpatient Prior Authorization program and continue to be responsible for claims adjudication.
- Please ensure that the member has not exhausted his/her benefit prior to providing services, even if an “Approved Authorization” has been obtained. The purpose of NIA is to verify medical necessity of physical medicine services, and not to manage the member’s benefits.
FREQUENTLY ASKED QUESTIONS
Which procedure codes require prior authorization?
Please note that the below list of NIA prior authorization procedure codes only affects outpatient physical medicine care for Medicaid. If services are rendered in the home, obtain prior authorization through Sunflower Health Plan.
| Code | Description | Category |
|---|---|---|
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual | Speech Therapy |
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals | Speech Therapy |
| 92526 | Treatment of swallowing dysfunction and/or oral function for feeding | Speech Therapy |
| 92606 | Therapeutic service(s) for the use of non-speech-generating device, including programming and modification | Speech Therapy |
| 96105 | Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour | Speech Therapy |
| 97010 | Application of a modality to 1 or more areas; hot or cold packs | Passive / Physical / Occupational |
| 97012 | Application of a modality to 1 or more areas; traction, mechanical | Passive / Physical / Occupational |
| 97014 | Application of a modality to 1 or more areas; electrical stimulation (unattended) | Passive / Physical / Occupational |
| 97016 | Application of a modality to 1 or more areas; vasopneumatic devices | Passive / Physical / Occupational |
| 97018 | Application of a modality to 1 or more areas; paraffin bath | Passive / Physical / Occupational |
| 97022 | Application of a modality to 1 or more areas; whirlpool | Passive / Physical / Occupational |
| 97024 | Application of a modality to 1 or more areas; diathermy (eg, microwave) | Passive / Physical / Occupational |
| 97026 | Application of a modality to 1 or more areas; infrared | Passive / Physical / Occupational |
| 97028 | Application of a modality to 1 or more areas; ultraviolet | Passive / Physical / Occupational |
| 97032 | Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes | Passive / Physical / Occupational |
| 97033 | Application of a modality to 1 or more areas; iontophoresis, each 15 minutes | Passive / Physical / Occupational |
| 97034 | Application of a modality to 1 or more areas; contrast baths, each 15 minutes | Passive / Physical / Occupational |
| 97035 | Application of a modality to 1 or more areas; ultrasound, each 15 minutes | Passive / Physical / Occupational |
| 97036 | Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes | Passive / Physical / Occupational |
| 97039 | Unlisted modality (specify type and time if constant attendance) | Passive / Physical / Occupational |
| 97110 | Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility | Physical / Occupational |
| 97112 | Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities | Physical / Occupational |
| 97113 | Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises | Physical Therapy |
| 97116 | Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) | Physical Therapy |
| 97124 | Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) | Passive / Physical / Occupational |
| 97127 | Therapeutic interventions that focus on cognitive function and/or pramatic functioning. | Passive / Physical / Occupational |
| 97140 | Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes | Passive / Physical / Occupational |
| 97150 | Therapeutic procedure(s), group (2 or more individuals) | Physical / Occupational |
| 97530 | Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes | Physical / Occupational |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes | Occupational Therapy |
| 97535 | Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes | Physical / Occupational |
| 97537 | Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes | Occupational Therapy |
| 97542 | Wheelchair management (eg, assessment, fitting, training), each 15 minutes | Physical / Occupational |
| 97545 | Work hardening/conditioning; initial 2 hours | Physical Therapy |
| 97546 | Work hardening/conditioning; each additional hour (List separately in addition to code for primary procedure) | Physical Therapy |
| 97750 | Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes | Physical Therapy |
| 97755 | Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes | Physical Therapy |
| 97760 | Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes | Physical / Occupational |
| 97761 | Prosthetic training, upper and/or lower extremity(s), each 15 minutes | Physical / Occupational |
| 97763 | Orthotic prosthetic management and/or training upper extremity, lower extremity and/or trunk, each 15 minutes | Physical / Occupational |
| 97164 | Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family. | Physical Therapy |
| 97168 | Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family. | Occupational Therapy |
| 95851 | Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) | The combination of contracted codes will determine if procedure is eligible. |
| 95852 | Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side | The combination of contracted codes will determine if procedure is eligible. |
How do I request a prior authorization for these services?
- You may submit the prior authorization request on the NIA website.
- You may call NIA at 1-877-644-4623.
What information is required to submit a prior authorization request? For additional specifics, see tip sheet (PDF).
- Member information
- Provider information
- Diagnosis code, body region being treated and date of evaluation
- Related pertinent clinical information from the evaluation
Helpful resources are available from NIA.
If you have questions about this bulletin or other provider resources, please contact Customer Service at 1-877-644-4623.