Update to the Rehabilitation Provider Manual -Appendix D 6-10-2019

The purpose of this update is to inform providers that the DMAS Rehabilitation Provider Manual, Appendix D, has been updated with information regarding Outpatient Rehab CPT code changes for physical and occupational therapy evaluations. Effective for dates of service on or after December 1, 2018, DMAS and all contracted Medicaid Managed Care Organizations (MCOs) in the Commonwealth Coordinated Care (CCC) Plus and Medallion 4.0 programs will provide coverage for the following Physical Therapy (PT) and Occupational Therapy (OT) evaluation codes:

- 97161 (Physical Therapy evaluation; low complexity);

- 97162 (Physical therapy evaluation; moderate complexity);

- 97165 (Occupational Therapy evaluation, low complexity); and

- 97166 (Occupational Therapy evaluation, moderate complexity).

DMAS currently covers CPT 97163 (Physical Therapy, evaluation; high complexity) and CPT 97167 (Occupational Therapy evaluation; high complexity). This coverage will not change.

These six codes will require service authorization by KEPRO for the Medicaid fee-for-service members. Providers may only use one code per member per date of service for each service authorization request. Specifics regarding the service authorization requirements can be found in Appendix D (Service Authorization) of the Rehabilitation Provider Manual using the following link:

These codes may require prior authorization by the Medicaid MCOs for the Managed Care members. Please contact the MCOs for their prior authorization policy for these codes. Please refer to the Rehabilitation Provider Manual, Appendix D (Service Authorization), for updated and new information.

Medicaid Expansion Eligibility Verification

Medicaid coverage for the new adult group begins January 1, 2019. Providers may use the Virginia Medicaid Web Portal and the Medicall audio response systems to verify Medicaid eligibility and managed care enrollment, including for the new adult group. In the Virginia Medicaid Web Portal, individuals eligible in the Medicaid expansion covered group will be shown as “MEDICAID EXP.” If the individual is enrolled in managed care, the “MEDICAID EXP” segment will be shown as well as the “MED4” (Medallion 4.0) or “CCCP” (CCC Plus) managed care enrollment segment. Additional Medicaid expansion resources for providers are available on the DMAS Medicaid Expansion webpage at:

See link for more details.

If trouble with link, use Virginia Medicaid Home link, go to Provider Resources tab, then to bottom of the drop down list to Provider Manual Updates/Revisions.



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