Medicaid physical therapy coverage by state: codes, authorization and limits
The short answerIt depends on the state. We found public physical therapy rules for 9 Medicaid programs: Arizona, Florida, Illinois, Michigan, New York, North Carolina, Ohio, Virginia and Washington. Each sets its own codes, prior authorization and limits, and managed care plans can add their own. Each state's page has its sources.
By Javier Alvarez · Updated · 4 min read
9 rows: Medicaid (by state). Public policy, not the member's benefits.
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] |
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] |
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] |
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] |
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] |
9 state Medicaid programs side by side
Each state runs Medicaid under its own manual and fee schedule, and managed care plans add their own rules on top. Each program below has its own page with every fact and its source.
| State | Codes | Prior authorization | Limits |
|---|---|---|---|
| Arizona AHCCCS | Not published: call the payer. | Not published: call the payer. | 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. |
| Florida Medicaid | Not published: call the payer. | Not published: call the payer. | 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. |
| Illinois Medicaid (fee-for-service) | Not published: call the payer. | 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. | 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. |
| Michigan Medicaid | Not published: call the payer. | 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. | 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. |
| New York Medicaid | Not published: call the payer. | Not published: call the payer. | Not published: call the payer. |
| North Carolina Medicaid | 6 of 9 listed | 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). | 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. |
| Ohio Medicaid | Not published: call the payer. | Not published: call the payer. | 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. |
| Virginia Medicaid | 2 of 9 listed | 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. | 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. |
| Washington Apple Health | 4 of 9 listed | 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. | 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. |
Your state isn't here?
We only add a state when we could open a document that states the rule. Call the state's provider line or the member's managed care plan, and ask which codes physical therapists can bill, whether prior authorization is needed and how many visits a year. The physical therapy table has every payer we checked.