Physical Therapy Code Description of Physical Therapy Evaluation, Low complexity, 20 N 1 $69.20 97162 Physical Therapy Evaluation, Moderate complexity, 30 N 1 $69.20 97163 Physical Therapy Evaluation, High complexity, 45 N 1 $69.20 97164 Physical Therapy Established plan of care N 1 $47.19 97010 of to 1 or more hot or cold packs N 10 $4.77 97012 Mechanical Traction (supervised) N 10 $12.67 97014 Electrical Stimulation (unattended) N 1 $12.52 97016 Device N 2 $15.37 97018 Paraffin Bath N 10 $8.76 Whirlpool N 10 $18.81 97024 Diathermy (e.g. microwave) N 10 $5.34 97026 Infrared N 10 $4.77 97028 Ultraviolet Light N 10 $5.87 97032 Attended Electrical each 15 N 4 $14.96 97033 Iontophoresis, each 15 minutes N 4 $17.48 97034 Contrast Bath, each 15-minutes N 4 $14.17 97035 Ultrasound, each N 4 $9.90 97036 Hubbard Tanks, each 15-minutes N 4 $26.01 97110 Therapeutic Procedure, each N 4 $29.03 97112 Reeducation N 4 $26.58 97113 Aquatic Therapy N 4 $33.98 97116 Gait Training N 4 $22.08 97124 Therapeutic N 4 $20.46 minutes minutes P
Massage 97140 Manual Therapy each 15 N 4 $23.45 97597 Selective (for wounds ≤ 20 sq. cm.) N 1 $59.82 97598 20 sq. cm N 1 $25.68 Negative pressure wound therapy N 1 $32.38 Total wound surface area ≥ 50 sq.cm. N 1 $38.27 Negative pressure therapy ≤ 50 sp. cm N 1 $37.79 97608 Negative pressure wound therapy > 50 sq. cm. N 1 $44.97 or N 3 $25.72 97755 Assistive each 15 N 2 $27.68 EPSDT Occupational Therapy Procedure Code Description Requires Pre-Auth Maximum Number of Maximum Payment 97165 Occupational Therapy Evaluation, Low complexity, 30 minutes N 1 $ 67.01 97166 Occupational Therapy Evaluation, Moderate complexity, 45 minutes No 1 $67.01 Occupational Therapy Evaluation, High Complexity, 60 minutes No 1 $67.01 97168 Occupational Therapy Re-Evaluation, Established plan of care N 1 $ 44.34 5 P
97530 Therapeutic Activities, each 15 minutes N 4 $ 30.56 EPSDT Speech Language Pathology Code Description of 92507 Individual N 1 $ 63.99 92508 Group N 1 $ 30.47 92521 Evaluation of speech fluency N 1 $ 91.35 92522 Evaluation of speech sound production N 1 $74.00 of speech with evaluation of language and N 1 $153.97 92524 and analysis of voice and N 1 $77.40 92526 Treatment of and/or oral function for feeding N 1 $80.85 of oral and function N 1 $81.43 Evaluation of auditory rehabilitation status N 1 $70.21 92627 Evaluation of auditory rehabilitation N 3 $17.37 92630 Auditory pre-lingual hearing loss N 1 $63.99 92633 Auditory post-lingual hearing loss N 1 $63.99 P
means of external attachment L8693 Auditory osseointegrated device, abutment, any length, replacement only L8694 Auditory osseointegrated device, transducer/actuator, replacement only, each V5160 Dispensing fee, binaural $175.00 V5170 Cros, in the ear V5180 Cros, BTE (behind the ear) V5210 Bicros, ITE (in the ear) V5220 Bicros, BTE (behind the ear) V5200 Dispensing fee, cros $106.00 V5240 Dispensing fee, bicros $106.00 V5254 Digital, monaural, CIC V5255 Digital, monaural, ITC V5256 Digital, monaural, ITE V5257 Digital, monaural, BTE V5258 Digital, binaural, CIC V5259 Digital, binaural, ITC V5260 Digital, binaural, ITE V5261 Digital, binaural, BTE V5241 Dispensing fee, monaural $106.00 *
SECTION III – Additional Preauthorization Information Prescribing Provider Name Telephone ( ) Address SECTION IV – Preauthorization Line Item Information DESCRPTION OF SERVICE PROCEDURE REQUESTED DATES OF SERVICE AUTHOR. AMOUNT CODE MOD UNITS AMOUNT FROM THRU UNITS $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ $ / / / / / / $ PREAUTHORIZATION NUMBER DOCUMENT CONTROL NUMBER SUBMIT TO TELLIGEN VIA QUALITRAC: (STAMP HERE) SECTION V – Specific Preauthorization Information Patient Location: Home Nursing Home Hospital In-Patient Discharge Date Address where equipment will be used (if different from above): Period of time requested: MFGR MODEL/PRODUCT NUMBER SINGLE UNIT PRICE AMT. PKG $ $ $ $ $