(1) This rule applies to services that are provided on or after January 1, 2008.
(2) Examinations and re-examinations may not be billed more than once every 30 days without prior authorization unless physician ordered. For the first visit and for each 30-day examination, the occupational therapist and physical therapist may charge for an office call in addition to treatment codes. For all other visits, the occupational therapist and physical therapist may charge only treatment codes without prior authorization. All examinations and re-examinations require a written report separate from the daily treatment note that reflects the claimant's functional status.
(3) Prior authorization is required before performing the procedures identified by codes 97535, 97537, 97545, 97546, and 97750.
(a) New procedures, for which a CPT code does not yet exist, and those procedures for which a numerical RVU has not been established, require prior authorization from the insurer.
(4) No more than two 15-minute units per day may be billed for each CPT code 97032, 97034, and 97035 without prior authorization. When ultrasound (CPT code 97035) and electrical stimulation (CPT code 97032) are used simultaneously in treatment, only the higher unit value of the two may be billed without prior authorization.
(5) Procedure codes 97110, 97112, 97113, 97116, 97140, 97530, 97532, 97533, and 97542, when billed alone, can be billed for no more than four 15-minute units in one day without prior authorization.
(6) Procedure code 97124, when billed alone, can be billed for no more than three 15-minute units in one day without prior authorization.
(7) No more than three unattended modality codes (97010 through 97028) may be billed each visit without prior authorization.
(8) If the patient's condition requires the use of unattended modalities only, no more than three unattended modalities (codes 97010 through 97028) may be billed per visit. Unattended modalities in the absence of any other treatment may not be billed for a period exceeding two calendar weeks without prior authorization.
(9) No more than a total of five codes may be billed per visit without prior authorization. With the exception of codes 97535, 97537, 97545, 97546, and 97750, each 15 minutes of a timed code is equivalent to the billing of one code for purposes of this rule.
(10) Code 97535 is to be used when training is conducted in the injured worker's home or at some other location outside of the therapist's office. Mileage and travel expenses shall be established with the insurer during prior authorization.
(11) See ARM 24.29.1517 for additional prior authorization requirements concerning medical services provided by occupational therapists and physical therapists.