Therapists at work

Practice Affairs → Practice

Practice strives to provide tools and resources to support the safe and effective provision of physical therapy services in all settings.

State Payer Advocacy Resource Center

APTA and the Private Practice Section have partnered to develop resources and tools to help PT’s address the overuse of prior authorization and utilization management barriers to medically necessary care. This new set of resources includes advice reversing payment denials, dealing with prior authorizations, template letters for patients and providers to legislators, insurance commissioners, employers and state Medicaid offices. This “members only” benefit can be accessed here: State Payer Resources

Update on Good Faith Estimate Requirements:

HHS has issued a revised “Frequently Asked Questions” document for the Good Faith Estimate Requirements for cash based practices. The updated document can be accessed here: Good Faith Estimate FAQ's

New Proposed ICD-10 codes

The CDC has proposed the addition of new ICD-10 codes and is accepting feedback from stakeholders. The new codes include codes in the “external causes” category for caught, crushed, jammed, or pinched between in or between objects and for social determinants of health indicating health insurance insecurity and income insecurity. If accepted, these codes could go into effect in October of 2022. More information is available here:

New Telehealth Place of Service Codes:

New place of service codes were published In January of 2022:
02: Telehealth Provided in location other than patient’s home (revised)
10: Telehealth Provided in the Patient’s Home (New)

Medicare contractors will not begin processing them until April 4, 2022, but some private insurers have already implemented the codes. Check with individual payers when billing for telehealth services. For more information: Telehealth code changes

Information Blocking Rules Update

The department of HHS instituted regulations designed to improve patients’ access to electronic health information in 2021. A new report details the 299 complaints received by HHS since the start of the program and 211 targeted health care providers. Make sure your practice is compliant with the rules by reviewing the: APTA Info Blocking Advisory.

CMS Changes to DMEPOS Prior Authorization and Face to Face Lists

On 1/13/22 CMS issued updates to the master list of DMEPOS items that could be moved to the list of items requiring either a Face to Face order prior to delivery or prior authorization. Some spinal and knee orthoses were added to the prior authorization list, but no upper extremity orthoses. For the required Face to Face encounter and written order prior to delivery list the only UE orthosis is: L3960, SEWHO, Airplane design, Prefabricated. There are 2 lumbar-sacral orthoses and 3 knee orthoses that were also added. For complete information see: Medicare Program DMEPOS list updates.

Cohere Nationwide Expansion

Humana has contracted with Cohere, a UMN, to handle authorization of therapy services including PT, OT and SLP for all commercial and Medicare Advantage plans. Cohere will replace Optum and in some areas, OrthoNet for all prior authorization for therapy. APTA staff and all component Pay Chairs attended a virtual meeting on 12/6/21 with Cohere and Humana, outlining the national transition.

Pay chairs were able to ask questions and express concerns.

  1. Is pre authorization required for initial evaluations: response: NO
  2. Is pre authorization required to issue an orthosis during the initial eval: NO
  3. Will treatment be covered at the same visit as the initial evaluation: Yes
  4. Authorization reviewers are nurses, orthopedic surgeons and PM&R physicians. Are any specialists in UE?: YES

A review of the recommended PRO measures and care paths does not include the upper extremity distal to the shoulder.

After reviewing Cohere’s responses, HUE submitted a list of concerns to APTA staff and Cohere responded on 2/8/22. The updated information follows:

  1. Prior authorization is not required for hand, thumb, wrist, forearm, and elbow conditions or humeral fractures with the exception of Xiaflex for Dupuytren’s contracture.
  2. A review of the recommended PRO measures and care paths does not include the upper extremity distal to the shoulder. Cohere’s response: PT for UE is not included under a dedicated care path. These diagnoses can still be submitted as a single service and assessed for approval, but prior approval is not required for payment. Any PRO measure can be submitted with the request for review.
  3. A review of the L codes on the prior authorization list reveals that no fracture braces are included and most pre- fabricated orthoses are not covered. Cohere’s response: Codes not listed on the prior authorization list are eligible for coverage-they just don’t require pre approval.
  4. Repair codes are also not covered and no guidance is available for replacements. Cohere’s response: Repair codes are covered and do not required prior authorization. There was no response regarding coverage for replacements.

Please contact Marsha at [email protected] to report coverage denials for UE rehab or orthoses.

OSHA Vaccine Mandate

On January 13, the United States Supreme Court halted the OSHA mandate requiring employers with 100 or more employees to get their employees vaccinated for COVID-19, or require unvaccinated employees to produce a negative test on at least a weekly basis, pending further evaluation at the Court of Appeals for the Sixth Circuit.

Practice Changes for 2022

Cash based practices face federal penalties for failing to provide “Good Faith Cost Estimates” to self-paying patients prior to starting care. APTA has created resources for practice owners , including links to Medicare templates, in order to help them remain compliant with the new rules. Treatment Estimates

Cigna and Orthosis Coverage

American Specialty Health (ASH), announced that the transition has been completed and they will process PT and OT claims for orthoses for CIGNA beneficiaries. Special acknowledgement to Liz Souza DPT CHT who spearheaded this effort!

Providers must request pre-authorization for orthoses beginning 12/22/21. A notice was posted to providers’ ASHLink accounts on12/22/21 listing the 23 approved orthosis codes and the repair code along with the fee schedule. Fracture braces, shoulder orthoses and most prefabricated orthoses do not appear on the list. Of note, custom fabricated elbow orthoses and prefabricated finger orthoses (ring orthoses) are also omitted. Providers are advised to review the list prior to providing orthoses for patients with CIGNA coverage.

ASH will automatically reprocess denied claims from May 1, 2021 through the end of the year, but practitioners should check to confirm their claims are being reprocessed.

WHO Clinical Case Definition for Long-Covid.

The WHO has developed a clinical case definition for residual symptoms from Covid-19. A comparison with the CDC definition can be found here: WHO clinical case definition

APTA COVID-19 Recommendations for members

APTA, AOTA and ASHA have issued a joint statement for professional action on COVID-19 vaccination and education, urging members to lead the way in adopting public health practices and guidance on vaccinations and masking in an effort to reduce COVID-19 infections. Details can be found here: COVID-19 Joint statement

State Practice News


With the addition of North Dakota and Rhode Island, there are now 8 states where PT’s are eligible to order radiographs.


The final 2022 PFS did not add PT’s or PTA’s as eligible telehealth providers under the Medicare program. CMS did add the following therapy codes as eligible telehealth services through the end of the calendar year in which the PHE ends. (Presently eligible through 12/31/22.)
97161 - 97164, 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761

Once the PHE ends, PT’s will not be able to provide these services via telehealth unless they are provided incident to an eligible telehealth provider. PTA’s cannot provide services incident to a non-PT provider.

Computer Based Technology Services: Permanent additions

Code Description
G2250 Remote assessment of recorded video or image
G2251 Virtual check in
98970-72 E-visit

Details regarding providing these services can be found at APTA guide to CBTS

PT’s and PTA’s remain eligible to deliver and bill for telehealth services and Telephone Assessments for Medicare beneficiaries through December 31, 2022.

Physical Therapist Assistants

PTA Differential
Beginning in 2022, services provided “in whole or part” by PTA’s will be reimbursed at 85% of the PFS.

IN part is defined as >10% of the 15” code performed solely by PTA (not PT and PTA together). If the PT and the PTA each perform billable time for the same CPT code, the services can be reported on separate claim lines with the appropriate modifier (CQ for PTA and GP for PT).

PTA Supervision
CMS revised the definition of direct supervision to include virtual presence of the supervising practitioner using interactive audio/video real-time communications technology in private practice. This remains in effect through the end of the year in which the PHE ends.

CMS made permanent changes proposed during the PHE permitting PT’s to delegate maintenance therapy in part B settings to their supervised PTA.