North Carolina Medicaid physical therapy coverage: codes, telehealth, limits and prior authorization
The short answerNC Medicaid covers outpatient PT with prior approval before treatment. Adults 21 and older get 30 PT/OT rehabilitative visits a year, approved up to 12 visits and six months at a time. Evaluations need no approval. 97140 is not telehealth eligible.
By Javier Alvarez · Updated · 1 min read
1 row: Medicaid (by state) · North Carolina. 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] |
What North Carolina Medicaid's documents say
The table above has every field we found for North Carolina Medicaid, with numbered sources. In short:
- 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).
- 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.
- 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.
- Codes. 97110, 97112, 97140, 97161, 97164 and 97530 are listed.
Check North Carolina Medicaid's claim against the row
Before the claim goes out, compare it with the row above: the evaluation code matches the complexity you documented, the timed codes fit the minutes, any prior authorization covers the visit, and the plan of care is signed when the payer asks for it. The physical therapy table compares Medicaid with every other payer we checked.