Texas Medicaid (fee-for-service) pediatric speech and OT coverage: codes, telehealth, limits and prior authorization
The short answerSLP and OT. Texas Medicaid pays chronic therapy for developmental delay from birth through age 20 with prior authorization. Evaluations need no authorization and are payable once every three years per provider. Assistants and clinical fellows cannot enroll. Timed PT and OT treatment is capped at 4 units (one hour) per discipline per day, and only one individual speech treatment is paid per day.
By Javier Alvarez · Updated · 1 min read
1 row: Medicaid (by state) · Texas. Public policy, not the member's benefits.
Texas Medicaid (fee-for-service)
TMPPM Vol. 2, Physical Therapy, Occupational Therapy, and Speech Therapy Services Handbook · Texas
| 92507 | Listed (telehealth allowed; one individual speech treatment per day) [1] |
|---|---|
| 92508 | Listed (group; once per date of service; telehealth allowed) [1] |
| 92521 | Listed (evaluation, no prior authorization) [1] |
| 92522 | Listed (evaluation, no prior authorization) [1] |
| 92523 | Listed (evaluation, no prior authorization) [1] |
| 92524 | Listed (evaluation, no prior authorization) [1] |
| 92526 | Listed (telehealth allowed) [1] |
| 97165 | Listed (oT evaluation, no prior authorization) [1] |
| 97166 | Listed (oT evaluation, no prior authorization) [1] |
| 97167 | Listed (oT evaluation, no prior authorization) [1] |
| 97168 | Listed (oT re-evaluation; telehealth allowed) [1] |
| 97530 | Listed (timed, counts toward the 4 unit daily cap; telehealth allowed) [1] |
| 97535 | Listed (timed, counts toward the 4 unit daily cap; telehealth allowed) [1] |
| Where it applies | Chronic PT, OT and speech therapy are benefits for medically necessary treatment of chronic conditions and developmental delay. All eligible clients from birth through 20 years old may continue to receive all medically necessary therapy with documentation of medical necessity. [1] |
| Diagnoses | For a speech developmental delay, language, articulation, apraxia and fluency each need at least one standardized test with a score 1.5 SD or more below the mean plus informal assessment documentation. Voice needs a medical evaluation. [1] |
| Telehealth rules | Synchronous audiovisual telehealth is allowed for OT evaluations (97165 to 97168), 97530, 97535, speech evaluations and speech treatment 92507, 92508 and 92526. Audio-only is not reimbursed. [1] |
| Visit limits | Evaluations are payable once every three years to the same rendering provider. Re-evaluations are payable once every 180 days for chronic services and once every 60 days for acute services. Timed PT and OT codes are limited to 4 units (one hour) per date of service per discipline. [1] |
| Prior authorization | Treatment needs prior authorization on the Texas Medicaid PT, OT, ST Prior Authorization Form. Initial evaluations do not need authorization. The initial request must reach TMHP within five business days of the first treatment, or earlier dates of service are denied. Chronic authorizations can run up to 180 days. [1] |
| Who can bill | Auxiliary personnel may take part under supervision, but Texas Medicaid will not pay for therapy given only by them. A licensed therapy assistant and a speech-language pathology intern (Clinical Fellow) cannot enroll as therapist providers. [1] |
| Also | Services on school premises are only allowed before or after school hours. Only school districts can deliver therapy during school hours, as School Health and Related Services (SHARS). A SHARS-eligible client can get additional Medicaid therapy only if medical necessity criteria are met. Co-treatment claims use modifier U3. [1] |
What Texas Medicaid (fee-for-service)'s documents say
The table above has every field we found for Texas Medicaid (fee-for-service), with numbered sources. In short:
- Prior authorization. Treatment needs prior authorization on the Texas Medicaid PT, OT, ST Prior Authorization Form. Initial evaluations do not need authorization. The initial request must reach TMHP within five business days of the first treatment, or earlier dates of service are denied. Chronic authorizations can run up to 180 days.
- Visit limits. Evaluations are payable once every three years to the same rendering provider. Re-evaluations are payable once every 180 days for chronic services and once every 60 days for acute services. Timed PT and OT codes are limited to 4 units (one hour) per date of service per discipline.
- Who can bill. Auxiliary personnel may take part under supervision, but Texas Medicaid will not pay for therapy given only by them. A licensed therapy assistant and a speech-language pathology intern (Clinical Fellow) cannot enroll as therapist providers.
- Codes. 92507, 92508, 92521, 92522, 92523, 92524, 92526, 97165, 97166, 97167, 97168, 97530 and 97535 are listed.
Codes we checked at Texas Medicaid (fee-for-service)
What Medicaid's own text says about one code: 92507 and 97530.
Other pediatric speech and OT rows for Texas
Texas autism coverage mandate (speech, OT, PT).
Check Texas Medicaid (fee-for-service)'s claim against the row
Before the claim goes out, compare it with the row above: the evaluation and treatment codes are ones the policy lists, the plan of care and any prior authorization cover the date, and the visit count fits the limit. The pediatric speech and OT table compares Medicaid with every other payer we checked.