CPAP Module 9, Section 5: Behavioral Health, PT/OT, and Rehab Services
MODULE 9: SERVICE LINE & SPECIALTY VARIATIONS

Section 5: Behavioral Health, PT/OT, and Rehab Services

Justifying the Process: A Masterclass in Authorizing Therapeutic Services by Duration, Frequency, and Functional Progress.

SECTION 9.5

Behavioral Health, PT/OT, and Rehab Services

From Product to Process: Translating Your Clinical Acumen to Service-Based Authorizations.

9.5.1 The “Why”: Justifying the Value of Time and Skill

In every section we have covered thus far, the “thing” you have been authorizing is a tangible product: a drug, an image, a machine. Now, we shift to the intangible. In rehabilitative and behavioral health services, the therapeutic intervention is not a product; it is a process. It is the skilled application of a therapist’s time, expertise, and guidance. You are authorizing sessions, visits, and courses of therapy. The “dose” is measured in minutes and the “frequency” is measured in visits per week. This requires a fundamental shift in your approach to justification.

This is a natural and critical evolution for a pharmacist PA specialist. Your entire career has been spent evaluating therapy, but you’ve focused on the pharmacological. You are an expert at determining if a patient is on the right dose of lisinopril. Now, you will apply that same clinical logic to determine if a patient needs two or three physical therapy sessions per week. You will use your data analysis skills not to evaluate trough levels, but to interpret a PHQ-9 score for depression or a measurement of knee flexion in degrees. You are uniquely suited for this role because you are a master of applied therapeutics.

The core challenge in this domain is answering the payer’s fundamental question: “How do we know this is working?” Since there is no pill to count, progress must be measured through functional improvement and documented with meticulous detail. Your job is to become the quality control expert for that documentation, ensuring that every request for continued service is backed by a clear, data-driven story of progress. You will be the one to coach the provider’s office, saying, “The request for more PT sessions was denied for ‘lack of progress.’ I’ve reviewed the notes, and the patient’s gait speed has improved by 15%. Let’s highlight that objective data in the appeal.”

In this final section of the module, you will learn to:

  • Think in Units of Service: Master the CPT codes that represent units of time (e.g., the 15-minute therapy code) and understand how they are bundled into a typical session.
  • Deconstruct the Treatment Plan: Learn to read and evaluate a therapist’s plan of care, identifying the key components payers look for: measurable goals, specific interventions, and a projected timeline.
  • Quantify Progress: Become fluent in the objective scales and measurements used in PT, OT, and behavioral health to demonstrate meaningful functional improvement.
  • Justify Continued Need: Master the art of arguing that a patient has made progress, but has not yet reached their maximum therapeutic potential, thus justifying another block of authorized sessions.

Success here is profoundly rewarding. It means securing the therapy that allows a stroke survivor to regain the ability to feed themselves, enabling a patient with crippling anxiety to return to work, or ensuring a child with developmental delays gets the support they need to thrive in school. You are moving beyond the pharmacy bench to become a central figure in a patient’s entire rehabilitative journey.

Retail Pharmacist Analogy: Managing a High-Touch MTM Program

Think about your experience with Medication Therapy Management (MTM), specifically a high-touch program like a comprehensive medication review (CMR) with follow-ups for a complex patient with diabetes and heart failure.

This program is a perfect analogy for the entire service-based authorization workflow.

  • The Initial Authorization (The CMR): The payer initially authorizes you to perform one comprehensive, 60-minute review. This is the “initial block” of therapy sessions. You have a specific CPT code to bill for this service.
  • The Plan of Care (The Medication Action Plan): At the end of the CMR, you don’t just say “take your meds.” You create a detailed Medication Action Plan (MAP). This plan identifies specific problems (e.g., uncontrolled hypertension, medication non-adherence) and sets measurable goals (e.g., “achieve BP < 130/80," "patient will use a pillbox and miss no more than 1 dose per week"). This is the therapist’s plan of care.
  • Requesting More “Sessions” (Justifying Follow-Up): You know this patient needs more than one visit. You submit a request to the payer for three 15-minute follow-up sessions. The payer asks for justification. You don’t just say “the patient needs more help.” You provide data. “Initial BP was 160/95. We initiated a new agent and provided education. Patient needs follow-up for BP monitoring, adherence assessment, and evaluation of side effects.” This is justifying the frequency and duration of therapy.
  • Documenting Progress (The Follow-Up Notes): At the first follow-up, the patient’s BP is down to 145/90. They are using their pillbox correctly. You document this progress meticulously. When you request the next block of sessions, your justification is even stronger: “Patient has demonstrated positive progress towards goals (BP reduction of 15/5 mmHg) but has not yet reached the therapeutic target. Continued follow-up is medically necessary to titrate therapy and reinforce adherence.” This is demonstrating functional improvement to prevent a denial for “lack of progress” or having “met goals.”

You are already an expert at justifying the need for your own clinical services based on a plan of care, measurable goals, and documented progress. Authorizing PT, OT, or behavioral health services uses the exact same logic, just with a different set of clinical metrics and CPT codes.

9.5.2 The Language of Service: CPT Codes, Units, and the Plan of Care

To operate in this world, you must learn its unique language. The currency of service-based care is the Current Procedural Terminology (CPT) code. Every therapeutic action, from a psychiatric diagnostic evaluation to a session of gait training, is represented by a 5-digit CPT code. Many of the most common therapy codes are “timed,” meaning they are billed in 15-minute increments or “units.”

Understanding this is critical. When a physical therapist requests “3 visits per week for 4 weeks,” the actual PA request you submit will be for a specific number of units of specific CPT codes. A single 60-minute PT session might actually be composed of four 15-minute units of different CPT codes billed together.

Masterclass Table: Common Timed CPT Codes in Rehab Therapy
CPT Code Description Discipline Pharmacist’s Insight
97110 Therapeutic Exercise PT/OT The most common code. Used for exercises to develop strength, endurance, range of motion, and flexibility.
97112 Neuromuscular Re-education PT/OT Used for activities that re-train movement, balance, coordination, posture, and proprioception. Think post-stroke or with Parkinson’s disease.
97530 Therapeutic Activities OT/PT This involves using dynamic activities to improve functional performance. This is a very common OT code (e.g., practicing grocery shopping, simulated cooking).
97535 Self-Care/Home Management Training OT The core of OT. This includes training in ADLs like bathing, dressing, and using adaptive equipment. The justification must link this code to a specific functional goal.
97116 Gait Training PT Focuses specifically on improving walking ability, including sequencing, posture, and use of assistive devices.
The Plan of Care: Your Central Justification Document

The single most important document for any service-based authorization is the therapist’s Plan of Care (POC). This is created during the initial evaluation and updated regularly. It is your primary source of truth. Before submitting any request, you must review the POC to ensure it contains the “golden trio” of elements that payers require.

1. Measurable, Functional Goals

Weak: “Improve strength.”
Strong: “Patient will increase right knee extension strength from 3/5 to 4/5 to allow for locking knee during ambulation.”
Weak: “Decrease anxiety.”
Strong: “Patient will demonstrate use of 2 coping mechanisms to reduce self-reported anxiety from 8/10 to 4/10 during exposure exercises.”

2. Specific Interventions

The POC must list the specific types of therapy that will be used, which should correspond to the CPT codes you are requesting. (e.g., “Interventions will include therapeutic exercise (97110) for quadriceps strengthening and gait training (97116) with a rolling walker.”).

3. Proposed Frequency & Duration

The request must be specific and justified. (e.g., “Requesting PT 3x/week for 4 weeks to maximize recovery in the acute post-operative phase. Will re-evaluate after 12 visits.”).

9.5.3 Masterclass Deep Dive: Behavioral Health Services

Behavioral health (BH) authorizations are among the most sensitive and complex. They require a deep respect for patient privacy combined with a rigorous, data-driven approach to justification. Payers are focused on ensuring the patient is being treated at the appropriate level of care (LOC) and that the therapy is making demonstrable progress in reducing symptoms and improving function.

Levels of Care: A Step-Therapy Approach

Payers view BH services on a continuum. A request for a higher, more intensive level of care will almost always be denied unless there is documentation that the patient has failed or is inappropriate for a lower level of care.

Level of Care Description Typical Authorization Pharmacist’s Justification Focus
Outpatient Therapy Standard “talk therapy.” Typically 1-hour sessions, 1-2 times per week. Initial block of 8-12 sessions often approved easily. Re-authorization requires proof of progress. Documenting use of validated scales (PHQ-9, GAD-7) to show symptom reduction over time.
Intensive Outpatient Program (IOP) A step up. Group and individual therapy, 3 hours per day, 3-5 days per week. Patient still lives at home. Requires PA for each week of treatment. Payer will conduct concurrent reviews. Proving that standard outpatient therapy was insufficient and the patient’s symptoms are causing significant functional impairment (e.g., inability to work or attend school).
Partial Hospitalization Program (PHP) The highest level of outpatient care. All-day programming (e.g., 6-8 hours), 5 days per week. A direct alternative to inpatient admission. Requires PA and is heavily scrutinized. Often requires daily clinical updates to the payer. Justifying that the patient is at imminent risk of harming themselves or others, or is so functionally impaired they cannot be safely managed at a lower LOC, but does not require 24/7 inpatient supervision.
The Art of the Continued Stay Review

For IOP and PHP levels of care, your work is never done after the initial approval. Payers will require a concurrent review every few days or every week to justify continued treatment. This means you must work with the clinical team to provide a concise, powerful update to the insurance case manager.

Pharmacist-Prepped “Concurrent Review” Script

“This is the weekly concurrent review for Jane Doe in our PHP program.
1. Progress Since Last Review: Jane has successfully developed and verbalized a safety plan. She has attended all groups and is actively participating. Her PHQ-9 score has improved from 22 to 18.
2. Remaining Deficits: Despite this progress, she continues to endorse passive suicidal ideation without a specific plan. She still struggles with significant amotivation and has not been able to complete her self-care ADLs at home over the weekend.
3. Justification for Continued Stay: The patient has shown positive engagement and initial symptom reduction but remains at an elevated risk and is not yet stable enough for a step-down to IOP. We are requesting an additional 5 days of PHP to reinforce safety planning and work on behavioral activation for ADLs. The estimated discharge date to our IOP is now [Date].”

9.5.4 Masterclass Deep Dive: Physical and Occupational Therapy

While often grouped together, PT and OT have distinct goals, and you must learn to articulate them separately. The key to both is demonstrating how the therapist’s interventions directly lead to an increase in the patient’s safety and independence. Denials in this space are almost always due to documentation that is either subjective (“patient feels better”) or fails to link an exercise to a real-world functional gain.

Physical Therapy (PT): The Science of Movement

The Goal of PT: To restore gross motor function, mobility, strength, and balance.

Your Justification Focus: Linking objective, measurable improvements in physical metrics to improved functional mobility.

Intervention (What the PT Does) Objective Measurement (The Data) Functional Goal (The “So What?”)
Therapeutic Exercise for quadriceps strengthening post-TKA (Total Knee Arthroplasty). Knee extension strength improves from 3+/5 to 4/5. Active knee flexion improves from 90° to 110°. Patient is now able to ascend/descend stairs with railing, and can rise from a chair without using hands.
Gait training with a walker for a patient post-hip fracture. Gait speed increases from 0.4 m/s to 0.7 m/s. Timed Up and Go (TUG) test improves from 25 seconds to 18 seconds. Patient can now safely ambulate from bedroom to bathroom, reducing fall risk and caregiver burden.
Occupational Therapy (OT): The Science of Daily Living

The Goal of OT: To restore a patient’s ability to perform meaningful Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs).

Your Justification Focus: Linking the use of specific strategies or adaptive equipment to the successful completion of a real-world task.

Intervention (What the OT Does) Objective Measurement (The Data) Functional Goal (The “So What?”)
Self-care training for a patient post-stroke with left-sided weakness. Level of assistance required for upper body dressing decreases from Maximal Assist to Minimal Assist. Patient is now able to don a shirt with setup assistance only, increasing their independence and sense of dignity.
Training in the use of adaptive utensils (built-up handles) for a patient with severe rheumatoid arthritis. Patient demonstrates ability to use the adaptive knife and fork to successfully cut food and feed self in 8 out of 10 trials. Patient is now able to eat independently, no longer requiring a caregiver to cut their food.
The “Plateau” Denial and How to Fight It

The most common reason for a continued therapy denial is that the payer believes the patient has “plateaued,” meaning they are no longer making significant functional gains. Your job is to become an expert at finding the data that proves this wrong.

The Script for the Appeal: “We are appealing the denial of continued physical therapy for this patient. While the rate of progress has slowed, the patient has not plateaued and continues to make small but functionally significant gains. As noted in the last progress report, their 6-minute walk test distance increased by another 50 feet. This incremental improvement is the difference between being homebound and being able to walk to the end of their driveway to get the mail. Terminating therapy now would be premature and would prevent the patient from reaching their maximum safe level of independence. We request an additional 6 visits to focus on achieving the final community ambulation goals.”