Claim Requirements for Therapy Evaluations and Re-evaluations

Date: 12/28/18

When submitting claims for therapy evaluations and re-evaluations, providers who serve Medicaid (STAR, STAR+PLUS, STAR Kids and STAR Health) and CHIP members are not required to bill a modifier in conjunction with the evaluations. Procedure codes are specific to the therapy type and therefore do not require a modifier in order to process the claim.

All claims submitted to Superior require valid data elements in order to be processed for payment. Claims submitted with unnecessary modifiers may cause denials or delays in claim processing.

The table below lists procedure codes by therapy type. When submitting claims, please ensure these codes are used without any additional modifiers.

Procedure Codes	Therapy Type
97165, 97166 or 97167	Occupational Therapy  Evaluation
97168	Occupational Therapy Re-evaluation
97161, 97162 or 97163	Physical Therapy Evaluation
97164	Physical Therapy Re-Evaluation
92521, 92522, 92523 or 92524	Speech Therapy Evaluation
S9152	Speech Therapy Re-Evaluation
92610	Speech Therapy Evaluation (swallowing function)

For questions, please contact your dedicated Account Manager or Provider Services at 1-877-391-5921.