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10.03.01o, Outpatient Physical Medicine, Rehabilitation, and Habilitation Services
Effective date
Jan 15, 2024
Identified
Sep 19, 2026
Summary
Independence Blue Cross reissued policy 10.03.01o with no substantive changes to coverage criteria for outpatient physical medicine, rehabilitation, and habilitation services. Billing teams must ensure modifier GP is appended to physical therapy claims and modifier GO to occupational therapy claims. Low-level laser therapy (LLLT/Photobiomodulation) and CPT 97037 remain non-covered as experimental/investigational.
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What to do
Action · 9 steps
01REQUIREMENTS:
- Effective immediately for all new claims on or after 01/15/2024: Billing team must update all billing system templates and claim submission rules to automatically append modifier GP to physical therapy procedure codes and modifier GO to occupational therapy procedure codes.
02This applies to all PT/OT CPT codes including 97012, 97014, 97016, 97018, 97022, 97024, 97028, 97032, G0283, S8950, S9476, and S9117.
03- Immediately: Remove CPT 97037 from medically necessary lists in billing software and configure system to deny claims using this code as experimental/investigational.
04Flag any historical claims with this code for potential recoupment review.
05- Immediately: Configure billing system to deny all claims for low-level laser therapy (LLLT) or Photobiomodulation Therapy with denial reason: experimental/investigational, not covered.
06- Before first claim submission: Providers and billing staff must be trained on new modifier requirements.
07Update encounter forms, superbills, and EMR templates to include modifier selection fields for PT/OT services.
08- Billing team should verify member benefits per contract, as PT/OT coverage varies by product, group, and state mandate status (particularly for ASD-related services).
09Non-compliance with modifier requirements will result in claim denials and payment delays.
Codes mentioned
9701297014970169701897022970249702897032G0283S8950S9476S8990S91179703795992
Original notice
10.03.01o, Outpatient Physical Medicine, Rehabilitation, and Habilitation Services
medpolicy.ibx.com · Always check the source before changing claims.
Related changes
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