North Carolina Medicaid Therapy Visit Limits for 2018
The following is an update on NC Medicaid therapy visit limitations for patients over 20 years old. These limits are from DMA Clinical Coverage Policy No: 10A (amended 12/15/2017). Medicare Cap
Medicaid patients who are over 20 are restricted to annual and episodic visit limits that are listed below. Annual therapy evaluations and treatment visits are separate and in addition to episodic visit limits. Episodic visits must be used before annual visits when the episode occurs before the use of annual visits.
All visit limits refer to combined PT, OT, and ST visits from all therapy providers in any outpatient setting, including hospital outpatient, home health, orthopaedic outpatient and any other outpatient setting. If multiple disciplines treat on the same date of service, each count separately toward the total visit limit.
The specific visit limits are as follows:
Episodic Limits
• A patient may have a total of 1 evaluation visit and 3 treatment visits:
o within 4 calendar months following a neurosurgical or musculoskeletal surgical procedure listed on Attachment A to DMA Coverage Policy 10A; or
o within 2 calendar months of cast removal, hardware removal (or both) or elimination of weight bearing restrictions or immobilization post musculoskeletal surgical procedure listed in Attachment A.
A new procedure allows for a new round of 1 evaluation and 3 treatment visits.
• A patient may have up to 2 therapy evaluations and a total of 8 treatment visits:
o within 6 calendar months of discharge from inpatient services for joint replacement or hip fracture surgery listed in Attachment A;
o within 2 calendar months of cast removal, hardware removal (or both) or elimination of weight bearing restrictions or immobilization post musculoskeletal surgical procedure listed in Attachment A; or
o within 6 calendar months of receiving an upper or lower extremity prosthesis.
A new joint replacement, hip fracture surgical procedure or receipt of new prosthesis allows for a new episode of 2 therapy evaluations and 8 treatment visits.
Annual Limits
• All patients may have 1 therapy evaluation per calendar year regardless of dx.
• A patient may have 1 evaluation visit and a total of 3 treatment visits per calendar year if he or she has a neurological or lymphedema diagnosis listed in Attachment A. (Evaluation and treatment visits prior to a patient’s 21st birthday count toward the annual visit limit for that calendar year.)
Note that these limits do not apply to patients who are under 21 years old, but preauthorization requirements still apply to these patients.
(Medicare Cap)
