Is this table the member's benefits?

No. It is what each payer publishes. The member's plan decides coverage, visit limits, authorization and cost sharing, so verify benefits before the first visit.

Each fact shows the day we opened its source. The latest check was October 30, 2026.

Free tools

Physical therapy coverage by payer and state, with sources

Q: What does "Unofficial source · confirm with the payer" mean?

The fact comes from a secondary source, such as a professional association or a billing guide, because we couldn't open the payer's own document. Confirm it with the payer before you rely on it.

The short answerWhat payers publish about physical therapy for physical therapists: which of 97161, 97162, 97163 and 97164 and the other codes each policy names, telehealth rules, visit limits and prior authorization, for 21 payers, state Medicaid programs and state laws. Every fact links to its source and the day we checked it.

By Javier Alvarez · Updated October 30, 2026 · 2 min read

Rows	21 payers, Medicaid programs and state laws, each with its own page
Codes	97161, 97162, 97163, 97164, 97110, 97112, 97140, 97530 and 97750
Sources	29 official documents, plus 2 secondary sources marked unofficial

21 rows: All payers and states. Public policy, not the member's benefits.

Medicare

Original Medicare (Part B), outpatient physical therapy · All states

97110	Listed (timed, 15 minutes per unit) [1][2]
97112	Listed (timed, 15 minutes per unit) [1]
97140	Listed (timed, 15 minutes per unit) [1]
97161	Listed (evaluation, low complexity. One unit per episode of care.) [1][3]
97162	Listed (evaluation, moderate complexity. One unit per episode of care.) [1]
97163	Listed (evaluation, high complexity. One unit per episode of care.) [1]
97164	Limited (re-evaluation. Not routine during a planned course of therapy; use modifier 59 or XU only if the patient status changes.) [1][3]
97530	Listed (timed, 15 minutes per unit) [1]
Where it applies	Original Medicare Part B pays for outpatient physical therapy under a plan of care. Every therapy claim must carry the GP modifier to show it is a physical therapy plan of care. [2]
Other codes	Also priced in the 2026 file: 97164 re-evaluation, 97116 gait training, 97535 self-care training, 97542 wheelchair management and 97750 physical performance test. Remote therapeutic monitoring codes 98976, 98977, 98979, 98984 and 98985 are sometimes-therapy codes. [1][4]
Telehealth POS	Use POS 02 for telehealth when the patient is not at home and POS 10 when the patient is at home. Telehealth to a patient at home pays at the non-facility rate. [5]
Telehealth rules	Physical therapists can furnish Medicare telehealth, including the telephone assessment and management codes, through December 31, 2027. From January 1, 2028 they can no longer furnish Medicare telehealth under current law. Audio-only is allowed for patients in their homes through December 31, 2027. [4][5]
Visit limits	For 2026 the KX modifier threshold is $2,480 a year for PT and speech-language pathology combined (OT has its own $2,480). Claims above it without KX are denied. The targeted medical review threshold stays at $3,000 until 2028. [6][4]
Referral	A physician or NPP must certify the plan of care. Initial certification is due within 30 calendar days of the first treatment day, and recertification at least every 90 calendar days or when the plan changes significantly. Since January 1, 2025 a dated written order or referral can stand in for the signature on the initial plan if the signed plan is not returned in 30 days and the chart shows the plan was delivered. [2]
Who can bill	A physical therapist can bill Medicare directly after enrolling as a private practitioner (solo, partnership, group, physician or NPP group, or an incorporated therapy practice). Services go in the therapist's or group's office or in the patient's home. [7]
Payment	2026 national amounts calculated from the CMS RVU file (total non-facility RVUs x $33.4009 conversion factor, before locality adjustment and the multiple procedure reduction): 97110 $29.06, 97112 $32.73, 97140 $27.72, 97530 $35.07, 97161 to 97163 $97.87 each, 97164 $67.47. [1]
Medicare rules	When a physical therapist assistant furnishes more than 10% of a service on their own, add CQ next to GP. Medicare pays CQ claims at 85% of the usual Part B amount. Do not use CQ when the PT does the whole service or when the PT and PTA treat together at the same time. [2]
Also	Timed codes follow the 8-minute rule: a single unit needs at least 8 minutes, and 23 minutes is the minimum for 2 units. The second and later therapy services on the same day get 50% of the practice expense component (MPPR). A progress report is needed at least once every 10 treatment days. [2][4]

CMS: PFS Relative Value Files, RVU26D (updated 08-26-2026), file PPRRVU2026_Oct_nonQPP, checked October 30, 2026
CMS: MLN905365, Complying with Outpatient Rehabilitation Therapy Documentation Requirements (September 2025, PDF), checked October 30, 2026
CMS: NCCI Medicare Policy Manual 2026, Chapter XI Medicine and E/M, 90000-99999 (rev. 1/1/2026, PDF), checked October 30, 2026
CMS: Therapy Services landing page, CY 2026 Therapy Services Updates (KX threshold, MPPR, CQ/CO, telehealth), checked October 30, 2026
CMS: Telehealth FAQ, updated 10/8/26 (PDF), checked October 30, 2026
CMS: Transmittal 13437 (Change Request 14252) / Transmittal 13437, 2026 Annual Update of KX Modifier Thresholds (Oct 30, 2025, PDF), checked October 30, 2026
CMS: Medicare Benefit Policy Manual, Chapter 15 (Rev. 13889, issued 07-30-26, PDF), checked October 30, 2026

UnitedHealthcare Medicare Advantage

UnitedHealthcare Medicare Advantage, outpatient therapy prior authorization · All states

97110	Limited (on the prior authorization code list) [1]
97112	Limited (on the prior authorization code list) [1]
97140	Limited (on the prior authorization code list) [1]
97161	Not named (the initial evaluation does not need prior authorization, but the evaluation results and care plan must be submitted with the request.) [1]
97164	Limited (on the prior authorization code list) [1]
97530	Limited (on the prior authorization code list) [1]
Where it applies	Applies to in-network providers for UnitedHealthcare Medicare Advantage individual (including chronic SNPs) and group retiree plans, plus added Arizona and California plans from Feb. 1, 2026. Excluded: out-of-network providers, Dual Complete, nursing home and assisted living plans, and several named regional plans. Reviews use applicable LCDs, CMS Chapter 15 criteria and InterQual. [1]
Other codes	The prior authorization code list includes 97110, 97112, 97116, 97140, 97164, 97530, 97535, 97542 and 97750, plus modalities such as 97012 to 97036. [1]
Telehealth POS	Therapy performed in the home (place of service Home) is excluded from the prior authorization program; existing Home Health program rules still apply. [1]
Visit limits	Up to 6 visits of the initial plan of care are covered without clinical review when they happen within 8 weeks, but the request must still be submitted. A plan of care with more than 6 visits or more than 8 weeks gets a medical necessity review. The 6-visit window applies if the member is new to the office, has a new condition, or had a gap in care of 90 days or more. [1]
Prior authorization	Prior authorization is required for outpatient PT delivered in an office or outpatient hospital, not in the home. The initial evaluation does not need it, but the request for the full plan of care (duration and number of visits) must be filed through the UnitedHealthcare Provider Portal, with the evaluation results and care plan. [1]

UnitedHealthcare: Prior authorization for outpatient therapy and chiropractic services, Medicare Advantage (updated Nov. 1, 2025, PDF), checked October 30, 2026

UnitedHealthcare Commercial

UnitedHealthcare Commercial and Individual Exchange reimbursement policies 2026R0098A and 2026R0121A · All states

97161	Listed (paid to physical therapists, not to physical therapist assistants) [1]
97162	Listed (paid to physical therapists, not to physical therapist assistants) [1]
97163	Listed (paid to physical therapists, not to physical therapist assistants) [1]
97164	Listed (paid to physical therapists, not to physical therapist assistants) [1]
Where it applies	Follows CMS: the GP (physical therapy) modifier is required on codes CMS designates as always therapy services, for dates of service on or after July 1, 2020. Applies to UnitedHealthcare Commercial and Individual Exchange plans billed on the CMS 1500. [1]
Who can bill	Physical therapists are reimbursed for evaluation and re-evaluation codes 97161 to 97164. Physical therapist assistants are not. Neither PTs nor PTAs are reimbursed for E/M codes 99202 to 99499, 99091 or G2252. [1]
Payment	Multiple therapy procedure reduction: the highest practice expense RVU procedure is paid without reduction, and the practice expense portion of every other reducible therapy procedure or unit on the same date, by the same group (same TIN), is reduced by 50%. It applies to multiple units of the same code too. [2]
Medicare rules	Modifier CQ is required for services furnished in whole or in part by a PTA (date of service on or after January 1, 2020), on the claim line with GP. "In part" means the PTA minutes exceed 10% of the total minutes for that service. CQ does not apply to PTA services that are incident to a physician or NPP. [1]
Also	The reduction list is the set of codes with indicator 5 in the CMS multiple procedure payment reduction field. It does not apply to flat-rate per diem contracts, and the CCI editing policy may also apply. [2]

UnitedHealthcare Commercial: Reimbursement Policy 2026R0098A, Physical Medicine & Rehabilitation, PT/OT Evaluation and Management (PDF), checked October 30, 2026
UnitedHealthcare Commercial: Reimbursement Policy 2026R0121A, Physical Medicine & Rehabilitation, Multiple Therapy Procedure Reduction (PDF), checked October 30, 2026

Aetna

Aetna Clinical Policy Bulletin 0325, Physical Therapy (last review 06/02/2026) · All states

97110	Listed (covered if the CPB 0325 criteria are met) [1]
97112	Listed (covered if the CPB 0325 criteria are met) [1]
97140	Listed (covered if the CPB 0325 criteria are met) [1]
97161	Listed (97161 to 97164 evaluation and re-evaluation, covered if criteria are met) [1]
97530	Listed (covered if the CPB 0325 criteria are met) [1]
Where it applies	Aetna considers PT medically necessary to significantly improve, develop or restore functions lost or impaired by disease, injury or surgery, when the practitioner expects significant improvement within one month or a safe maintenance program can be set up. Services must be done by a licensed PT, or under supervision where state law allows, and follow a written plan of care. [1]
Other codes	The covered-code table also lists 97116 gait training, 97535 self-care training, 97537 community reintegration training, 97542 wheelchair management and 97760 to 97763 orthotic and prosthetic codes. [1]
Visit limits	Typically, in Aetna HMO plans the PT benefit is limited to a 60-day treatment period per condition (calendar year, contract year or lifetime, depending on the plan); a new condition, such as surgery, can start a new 60-day course. In HMO, QPOS, Health Network Only and Health Network Option plans, short-term home-based PT also counts toward the 60-day limit or other rehab benefit limits. [1]
Who can bill	Services must be performed by a duly licensed (and certified, if applicable) PT within scope of practice. Physicians cannot directly supervise physical therapy assistants because they are not licensed as physical therapists. [1]
Also	Not medically necessary: PT in asymptomatic people, PT when the condition is neither regressing nor improving, and supervised PT once the benefit is reached or a home exercise program would do. Documentation: diagnosis with onset date, goals, evaluation, frequency and duration, techniques, PT signature, and re-evaluation at least monthly. [1]

Aetna: Clinical Policy Bulletin 0325, Physical Therapy (last review 06/02/2026), checked October 30, 2026

Cigna

Cigna / ASH Medical Coverage Policy CPG 135 and Cigna policy 0600 · All states

97110	Listed (medically necessary when the policy criteria are met) [1]
97112	Listed (medically necessary when the policy criteria are met) [1]
97140	Listed (medically necessary when the policy criteria are met) [1]
97161	Listed (medically necessary when the policy criteria are met) [1]
97530	Listed (medically necessary when the policy criteria are met) [1]
Where it applies	Policy CPG 135 is a Cigna / ASH Medical Coverage Policy effective 12/15/2025. Under many Cigna plans, outpatient PT falls under the plan's Short-Term Rehabilitative Therapy benefit and its limits, and the plan document overrides the policy. Habilitative PT may or may not be covered. [1]
Telehealth POS	Site of care: PT in an outpatient hospital (POS 19 off-campus or POS 22 on-campus) is medically necessary only when specialized equipment or personnel, coordinated multidisciplinary expertise, no freestanding PT/OT facility within reasonable distance, or an equity barrier applies. Any other indication is not medically necessary (policy 0600, effective 8/15/2026). [2]
Visit limits	Outpatient PT is limited to a maximum of 4 timed codes (about one hour) per date of service per provider; time beyond that is not covered or reimbursable. Visit maximums come from the member's benefit plan, not from the policy. [1]
Also	When a patient gets manual therapy from a PT and chiropractic or osteopathic manipulation, the services must be documented as separate and distinct, on different body parts, and justified and non-duplicative. More than two passive modalities on a visit date should be justified in the documentation. [1]

Cigna / ASH: Medical Coverage Policy CPG 135, Physical Therapy (effective 12/15/2025, PDF), checked October 30, 2026
Cigna: Medical Coverage Policy 0600, Site of Care: Outpatient Hospital Setting for Physical and Occupational Therapy (effective 8/15/2026, PDF), checked October 30, 2026

Blue Cross Blue Shield of Michigan and BCN

BCBSM / BCN PT, OT, ST and physical medicine utilization management (revised June 2026) · Michigan

Where it applies	The eviCore program in this document applies to BCN commercial and BCN Advantage. For other plans the document points to separate prior authorization requirements and the provider portal for details. [1]
Prior authorization	EviCore by Evernorth decides prior authorization for PT and OT for BCN commercial (all fully insured groups, all self-funded groups and all individual members) and BCN Advantage (all groups and members). [1]
Also	Blue Cross and BCN commercial self-funded groups can buy the Hinge Health virtual exercise therapy program: 12 visits a year with a Hinge PT, no referral or prior authorization, and it does not count toward in-person benefit limits. [1]

Blue Cross Blue Shield of Michigan / Blue Care Network: PT, OT, ST and physical medicine services, prior authorization determinations (revised June 2026, PDF), checked October 30, 2026

BCBS Rhode Island Medicare Advantage

BCBSRI Medicare Advantage, prior authorization of physical and occupational therapy (effective 1/1/2026) · Rhode Island

Where it applies	Applies to Blue Cross & Blue Shield of Rhode Island Medicare Advantage plans only. The review vendor is eviCore, and the ordering therapist starts the notification or authorization. A visit means a date of service. [1]
Prior authorization	Effective 1/1/2026, Medicare Advantage plans need notification for PT visits 1 to 14 per episode of care (including the evaluation), which administratively authorizes up to 14 visits. Prior authorization is required after the 14th visit. Telehealth, home health and inpatient PT do not need either. [1]
Also	Codes are covered only if approved by the vendor, and benefits vary between groups and contracts. [1]

Blue Cross & Blue Shield of Rhode Island: Medical Coverage Policy, Prior Authorization of Physical and Occupational Therapy Services, Medicare Advantage (effective 1/1/2026, PDF), checked October 30, 2026

North Carolina Medicaid

NC Medicaid Clinical Coverage Policy 10A, Outpatient Specialized Therapy Services (amended Oct 1, 2026) · North Carolina

97110	Listed (1 unit = 15 minutes; telehealth eligible) [1]
97112	Listed (1 unit = 15 minutes; telehealth eligible) [1]
97140	Listed (1 unit = 15 minutes; not telehealth eligible) [1]
97161	Listed (pT evaluation, 1 unit = 1 event; telehealth eligible) [1]
97164	Listed (pT re-evaluation, 1 unit = 1 event; telehealth eligible) [1]
97530	Listed (1 unit = 15 minutes; telehealth eligible) [1]
Telehealth modifier	Modifier GT must be appended to the CPT or HCPCS code to show the service was delivered by interactive audio-visual communication. [1]
Telehealth rules	NC Medicaid added telehealth for select PT and OT codes. Telehealth eligible: 97161 to 97164, 97110, 97112, 97116, 97530, 97535, 97542 and 97750. Not eligible: 97140 and the 97010 to 97036 modalities. [1]
Visit limits	For age 21 and older, one prior approval covers up to 12 treatment visits and six months. Each calendar year the maximum is 30 treatment visits combined across occupational and physical therapy rehabilitative services, and a separate 30 for habilitative. [1]
Prior authorization	Prior approval is required before treatment starts, requested from the DHHS utilization review contractor. It is not required for an evaluation or a re-evaluation visit, or for treatment of a patient who is also on Medicare (Medicare policy applies). [1]
Referral	A verbal or written order is required before any outpatient specialized therapy service. A verbal order must be countersigned by the ordering practitioner within 60 calendar days. [1]
Also	A written evaluation report must be completed within three months of the requested treatment start date, and an annual re-evaluation is needed when treatment continues. Approval is medical approval only and does not guarantee payment or eligibility. [1]

NC Medicaid: Clinical Coverage Policy 10A, Outpatient Specialized Therapy Services (amended Oct 1, 2026, PDF), checked October 30, 2026

Washington Apple Health

Washington Apple Health Outpatient Rehabilitation Billing Guide (Jan 1, 2026) · Washington

97110	Listed (counts toward the 24-unit adult limit; on the audio-visual telemedicine list) [1]
97140	Listed (timed 15-minute units, GP or GO; counts toward the 24-unit adult limit) [1]
97161	Listed (evaluation; on the audio-visual telemedicine list) [1]
97530	Listed (timed 15-minute units, GP or GO; on the audio-visual telemedicine list) [1]
Telehealth rules	HCA pays for PT evaluation, re-evaluation and treatment by audio-visual telemedicine with specific codes (97161 to 97164, 97110, 97112, 97116, 97150, 97530, 97535, 97750) when clinically appropriate. Audio-only is not allowed for outpatient physical or occupational therapy. [1]
Visit limits	Clients age 21 and older (and MCS clients 19 to 20) get 24 PT units, about 6 hours, per calendar year in any setting, plus one evaluation and one re-evaluation at discharge a year. Clients 20 and younger have unlimited outpatient rehabilitation (except MCS ages 19 to 20). Check available units with HCA before treating. [1]
Prior authorization	Expedited prior authorization (EPA) adds up to 24 more units for listed diagnoses, such as non-healing wounds, burns, brain injury and stroke with residual deficits, and one extra evaluation for a new injury. Units beyond that need a limitation extension. [1]
Who can bill	Licensed physical therapists enroll with HCA. PTA services need CQ on the claim line along with GP, or the claim is rejected as unprocessed. [1]
Also	A new therapy prescription in the same calendar year requires an authorization for a new evaluation before more care, even if units remain. Extra units are tied to the condition they were authorized for and do not roll over. [1]

Washington Health Care Authority: Apple Health Outpatient Rehabilitation Billing Guide (Jan 1, 2026, PDF), checked October 30, 2026

Ohio Medicaid

Ohio Administrative Code 5160-8-35, Skilled therapy services (effective January 1, 2024) · Ohio

Visit limits	Physical therapy in a non-institutional setting is paid without prior authorization for not more than thirty visits per benefit year. More visits can be requested through prior authorization under rule 5160-1-31. Evaluations are paid not more than once per injury or condition. [1]
Referral	PT must be rendered in response to a prescription from a licensed practitioner of the healing arts, and the evaluation and treatment plan must be kept on file. [1]
Who can bill	Physical therapists (and mechanotherapists) can bill for their own services. A licensed physical therapist assistant can render a service under supervision to one individual at a time. Hospitals, physician practices, professional medical groups, ambulatory health care clinics, FQHCs and RHCs can bill for a rendering therapist. [1]
Payment	When more than one therapy service of the same discipline is rendered the same day, the highest-paying one is primary and pays 100% for its first unit. Each additional unit or procedure in the same discipline pays 80%. Payment is the lesser of the charge or a percentage of the appendix DD fee amount. [1]
Also	Unattended electrical stimulation and iontophoresis are part of the associated therapy procedure and are not paid separately. Evaluation prognosis must show expected improvement within sixty days for rehabilitative therapy, or a safe maintenance program. Payment is made only for services listed in the treatment or maintenance plan. [1]

Ohio Administrative Code Rule 5160-8-35, Skilled therapy services (effective January 1, 2024), checked October 30, 2026

New York Medicaid

eMedNY Rehabilitation Services Manual Policy Guidelines 2024-1 and Fee Schedule 2026-V1 · New York

Where it applies	Visits in private practitioners' offices, certified hospital outpatient departments and free-standing diagnostic and treatment centers are covered when medically necessary. Therapy is medically necessary when there is a treatment plan with measurable goals, an identifiable diagnosis, a reasonable expectation of measurable functional outcomes and it is not duplicate therapy. [1][2]
Telehealth modifier	The GP modifier (services under an outpatient physical therapy plan of care) must be used with therapy procedure codes on Medicaid claims. NCCI associated modifiers are recognized for code pairs. [1]
Referral	PT must be ordered in writing by a physician, physician assistant or nurse practitioner authorized by law. An evaluation is required before any treatment plan is implemented. [2]
Who can bill	A qualified practitioner is a licensed therapist working within scope. PT assistants can provide services under the direction and supervision of the physical therapist. Aides, athletic trainers, exercise physiologists and rehabilitation technicians do not qualify regardless of supervision. [2]
Payment	January 2026 eMedNY non-facility fees (private office only): the PT/OT section lists 97530 $18.05 and 97542 $44.58; eVisits 98970 $9.42, 98971 $16.61, 98972 $26.74. Other common PT codes (97110, 97112, 97140, 97161 to 97164) are not on this schedule. In other settings (D&TC, hospital outpatient, nursing home) the therapist cannot bill Medicaid directly and the institution is paid. Fees are payment in full. [1]

NY Medicaid (eMedNY): Rehabilitation Services Procedure Codes & Fee Schedule, 2026-V1 (PDF), checked October 30, 2026
NY Medicaid (eMedNY): Rehabilitation Services Manual Policy Guidelines, Version 2024-1 (PDF), checked October 30, 2026

Michigan Medicaid

MDHHS Medicaid outpatient therapy guide (2024 coverage and FFS prior authorization) · Michigan

Telehealth modifier	Therapy PA requests and claims must carry GP for physical therapy. Habilitative therapy adds modifier 96, and maintenance therapy adds modifier TS. [1]
Telehealth rules	Some therapy services may be provided via telemedicine (check the state telemedicine database for covered services). Evaluations must be performed in person. Group therapy is not covered. [1]
Visit limits	Fee-for-service Medicaid covers up to 144 units of PT per calendar year for rehabilitative therapy (and the same for habilitative therapy when the beneficiary is eligible). Maintenance therapy is covered up to 4 visits per 90 days, with those 4 visits not exceeding 16 units. More requires prior authorization. [1]
Prior authorization	PA is needed when rehabilitative or habilitative PT exceeds 144 units a year, or maintenance exceeds 4 times or 16 units per 90 days. Continued therapy can be requested up to 6 months at a time, at least three weeks before the limit. PA is not granted retroactively; submit form MSA-115 with the evaluation, prior-period summary, goals, and prescription. [1]
Referral	All services must be ordered by the beneficiary's primary care or specialty medical provider. [1]
Managed care plans	The benefit and PA rules apply to fee-for-service. Medicaid Health Plans and Integrated Care Organizations must cover the services but may set different PA requirements, so check with the member's plan. [1]

Michigan MDHHS: Medicaid Guide for Beginners, Outpatient Therapy Services (2024 coverage and FFS prior authorization, PDF), checked October 30, 2026

Virginia Medicaid

DMAS Rehabilitation Provider Manual, Appendix D Service Authorization (9/24/2026) · Virginia

97110	Listed (1 unit = 15 minutes) [1]
97161	Listed (evaluation, 1 unit = an evaluation) [1]
Other codes	Private rehabilitation agencies, CORFs and physician providers request authorization with CPT codes: 97110 and 97112, 97140 and the 97161 to 97163 evaluations are among the listed codes (1 unit = 15 minutes for timed codes, 1 unit = an evaluation for evaluations). [1]
Visit limits	Fee-for-service members get 5 visits per rehabilitative discipline per state fiscal year (July 1 to June 30) without service authorization, counting the initial evaluation and all providers combined. The limit renews every July 1, and the provider must use those first five before the authorization number applies. Managed care members follow their MCO's rules. [1]
Prior authorization	Service authorization requests go to Acentra Health through its Atrezzo Next Generation portal. Authorization is required before payment for any units over five a year, so a provider who knows treatment will go beyond 5 visits must request it. [1]

Virginia DMAS: Rehabilitation Provider Manual, Appendix D Service Authorization (revised 9/24/2026, PDF), checked October 30, 2026

Arizona AHCCCS

AHCCCS Medical Policy Manual 310-X (effective 10/01/25) · Arizona

Visit limits	Adults 21 and older (Acute and ALTCS) get 15 outpatient PT visits per benefit year to restore a skill or level of function, and another 15 visits per benefit year to acquire a new skill or level of function. A visit is PT services received in one day. [1]
Referral	PT must be ordered by the member's PCP or attending physician and be part of the individualized plan, which the PCP, attending physician or nonphysician practitioner reviews at least every 62 days. [1]
Who can bill	PT must be provided by a qualified physical therapist or by a qualified individual under the physical therapist's supervision. Members at home or in an HCBS or institutional setting get PT through a Medicare-certified home health agency or an independent practice physical therapist. [1]
Also	Outpatient PT is not covered as a maintenance program. For members who also have Medicare, AHCCCS cost-sharing coverage follows ACOM Policy 201. Prior authorization requirements for fee-for-service are in AMPM Policy 820. [1]

AHCCCS: Medical Policy Manual Chapter 300, Policy 310-X Occupational, Physical, and Speech Therapies (effective 10/01/25, PDF), checked October 30, 2026

Florida Medicaid

Florida AHCA Therapy Services, Physical (covered services page) · Florida

Where it applies	Florida Medicaid reimburses physical therapy that includes castings and strappings, evaluations and treatments. It is one of the minimum covered services for all Managed Medical Assistance and Long-Term Care plans. [1]
Visit limits	Recipients 20 and younger not in a long-term care plan may get PT under the coverage and limitations policy. Recipients 21 and older may receive limited services pertaining to wheelchair evaluations and fittings. [1]
Also	Recipients 18 and older who are enrolled in one of the state's Long-Term Care plans (the manual names two plan types) may receive physical therapy. [1]

Florida AHCA: Therapy Services, Physical (Florida Medicaid covered services page), checked October 30, 2026

Illinois Medicaid (fee-for-service)

HFS Handbook for Therapy Providers, Chapter J-200 (issued July 2016) · Illinois

Visit limits	The 2012 limit of 20 visits per year per discipline for adults was later removed by Public Act 098-0651, which still required prior approval for all therapy services. [1]
Prior authorization	Per the HFS therapy handbook (July 2016), fee-for-service prior approval is required for all therapy services except a therapy evaluation visit, services approved by Medicare, services paid by an MCO, and speech therapy for children through age 20. HFS has required it for adults since July 1, 2012, and for PT and OT for children through age 20 since November 16, 2015. Services billed without required approval are not paid. [1]
Managed care plans	If a participant joins an MCO or MCCN during an approved period, the HFS prior approval no longer applies from the managed care enrollment date, and requests go to the plan. [1]

Illinois HFS: Handbook for Therapy Providers, Chapter J-200 Policy and Procedures (issued July 2016, PDF), checked October 30, 2026

Humana

Humana commercial, Medicare Advantage and dual plans, outpatient physical therapy · All states

Unofficial source · confirm with the payer: some facts in this row come from a secondary source, not the payer.

97110	Listed (on the prior authorization list the vendor publishes for Humana.) [1] Unofficial source · confirm with the payer
97112	Listed (on the prior authorization list the vendor publishes for Humana.) [1] Unofficial source · confirm with the payer
97140	Listed (on the prior authorization list the vendor publishes for Humana.) [1] Unofficial source · confirm with the payer
97164	Listed (on the prior authorization list the vendor publishes for Humana.) [1] Unofficial source · confirm with the payer
97530	Listed (on the prior authorization list the vendor publishes for Humana.) [1] Unofficial source · confirm with the payer
97750	Listed (on the prior authorization list the vendor publishes for Humana.) [1] Unofficial source · confirm with the payer
Where it applies	Cohere Health says it is the exclusive preauthorization and utilization management vendor for Humana musculoskeletal services in all 50 states and Washington, DC, for most commercial and Medicare plans. [1] Unofficial source · confirm with the payer
Prior authorization	Physical, occupational and speech therapy codes are on the list of services practices must request through Cohere, including 97110, 97112, 97140, 97164, 97530 and 97750. The page does not list the evaluation codes 97161 to 97163. [1] Unofficial source · confirm with the payer
Managed care plans	Cohere says it will not be used for Medicare HMO members in FL, CA and HI. Those members keep getting authorizations through their primary care provider. [1] Unofficial source · confirm with the payer
Also	Cohere says an approval is not a guarantee of payment, and tells practices to check Humana's official prior authorization list at humana.com/pal for current requirements. Outpatient therapy in a skilled nursing facility billed under Medicare Part B also goes through Cohere. [1] Unofficial source · confirm with the payer

Cohere Health Learning Center: Humana Prior Authorization List (PAL), Musculoskeletal Services (July 1, 2026) (secondary source), checked October 30, 2026

TRICARE

TRICARE outpatient physical therapy (billing detail is TRICARE West Region) · All states

97110	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
97112	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
97140	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
97161	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
97162	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
97163	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
97164	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
97530	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
97750	Listed (inside the PT procedure ranges in the West Region billing guide.) [1]
Where it applies	TRICARE covers physical therapy provided by a licensed physical therapist, or a PT assistant under the supervision of a TRICARE-authorized PT, to aid recovery from disease or injury. [2]
Other codes	The West Region guide lists the physical therapy procedure ranges 97010 to 97530 and 97542 to 97750, among others. Orders can come from a physician, PA, NP or podiatrist. [1]
Visit limits	TRICARE does not cover several PT services, including general exercise programs and maintenance therapy. Its list is not all inclusive, and it tells providers to contact their regional contractor for specific limits. [2]
Referral	In the West Region, every therapy claim must meet one of three conditions: a PCM referral with TriWest approval, the referring provider listed on the claim, or physician orders faxed or mailed to PGBA. The guide recommends listing the referring provider to avoid payment delays. [1]
Also	The TriWest guide covers the West Region only. The East Region contractor, Humana Military, was not checked. [1]

TriWest (TRICARE West Region): Billing for Physical, Occupational, and Speech Therapies Criteria QRG (Aug 26, 2026, PDF), checked October 30, 2026
TRICARE: Physical Therapy, covered services (updated 10/1/2026), checked October 30, 2026

Florida direct access

Florida Statutes s. 486.021, practice of physical therapy · Florida

State law	A Florida physical therapist may implement a plan of treatment developed by the physical therapist for a patient, or provided by a practitioner of record or an APRN. [1]
Referral	If physical therapy is needed beyond 30 days for a condition not previously assessed by a practitioner of record, the PT must have a practitioner of record review and sign the plan. [1]
Also	The PT must refer the patient to or consult with a practitioner of record if the condition is outside the scope of physical therapy. The statute does not say what a health plan must pay. [1]

Florida Statutes s. 486.021, Physical Therapy Practice definitions (Florida Legislature), checked October 30, 2026

Ohio direct access

Ohio Revised Code s. 4755.481 · Ohio

State law	An Ohio PT may evaluate and treat a patient without a prescription or referral. With the patient's consent, the PT must inform the relevant practitioner of the evaluation within five business days. [1]
Referral	If there is no substantial progress in the 30 days after the first visit, the PT must consult with or refer the patient to a practitioner. Exceptions apply for fitness, wellness or prevention, and for previously diagnosed chronic, neuromuscular or developmental conditions. [1]
Payment	The law says nothing in these sections requires reimbursement under a health insuring corporation policy, a sickness and accident policy, Medicaid, or the listed workers' compensation programs for PT rendered without a prescription or referral. [1]

Ohio Revised Code s. 4755.481, Treatment without prescription or referral (Ohio Laws), checked October 30, 2026

Texas direct access

Texas Occupations Code s. 453.301 · Texas

Unofficial source · confirm with the payer: some facts in this row come from a secondary source, not the payer.

State law	A Texas PT may treat without a referral if licensed at least one year, covered by professional liability insurance, and holding a DPT or 30 hours of continuing competence in differential diagnosis. [1] Unofficial source · confirm with the payer
Visit limits	Treatment without a referral is limited to 10 consecutive business days, or 15 for a PT with a DPT who also completed a residency or fellowship or holds an approved certification. A referral is required to continue past that. [1] Unofficial source · confirm with the payer
Also	A PT who treats without a referral must get a signed disclosure in which the patient acknowledges that the patient's health insurance may not include coverage for the PT's services. [1] Unofficial source · confirm with the payer

Texas Occupations Code s. 453.301, as reproduced by Texas.Public.Law (statute text accessed May 2025) (secondary source), checked October 30, 2026

How to use the table

Pick a payer, a state or a code, and the table keeps only the rows that match. Open a row for every field and its numbered sources. A fact marked "Unofficial source · confirm with the payer" comes from a secondary source, such as a professional association or a billing guide, because we couldn't open the payer's own document; check it with the payer before you rely on it.

Every payer and state on the table

National payers: Medicare, UnitedHealthcare Medicare Advantage, UnitedHealthcare Commercial, Aetna, Cigna, Humana (unofficial), TRICARE.
Regional plans and contractors: Blue Cross Blue Shield of Michigan and BCN, BCBS Rhode Island Medicare Advantage.
Medicaid: all states side by side, and North Carolina Medicaid, Washington Apple Health, Ohio Medicaid, New York Medicaid, Michigan Medicaid, Virginia Medicaid, Arizona AHCCCS, Florida Medicaid, Illinois Medicaid (fee-for-service).
State laws: side by side, and Florida direct access, Ohio direct access, Texas direct access (unofficial).

Codes by payer

What a payer's own text says about one code: units, time rules, authorization and who can bill it.

97112: Medicare.
97140: Medicare.
97161: Medicare.
97164: Medicare.

Where the facts come from

From the payer's own policy, provider manual or fee schedule, from CMS for Medicare, a state Medicaid agency or the statute itself: 29 official documents. Where no official document could be opened, from a secondary source that we cite and label: 2 of them. Each fact links to its source and shows the day we opened it (October 30, 2026 for the latest). No source, no fact.

The same table exists for dietitians and MNT, and for psychotherapy, pediatric speech and OT and psychological testing.