Massage 97140 Manual N 4 $23.45 Therapy 97597 Selective N 1 $59.82 each 15 (for 97598 N 1 $25.68 wounds ≤ 20 sq. cm.) Negative N 1 $32.38 pressure Total wound N 1 $38.27 wound surface area ≥ therapy 50 sq.cm. Negative N 1 $37.79 pressure therapy 50 ≤ 97608 Negative N 1 $44.97 sp. cm pressure wound N 3 $25.72 P therapy > 50 sq. cm. 97755 N 2 $27.68 Assistive 20 sq. cm each 15 EPSDT Occupational Therapy Procedure Description Requires Maximum Maximum Code Pre-Auth Payment Number or of 97165 Occupational Therapy N 1 $ 67.01 Evaluation, Low complexity, 30 minutes 97166 Occupational Therapy No 1 $67.01 Evaluation, Moderate complexity, 45 minutes Occupational Therapy No 1 $67.01 Evaluation, High Complexity, 5 60 minutes 97168 Occupational Therapy N 1 $ 44.34 Re-Evaluation, Established plan of care
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
Audiology,%20Physical%20Therapy,%20and%20EPSDT%20Provider%20Manual%206%2021%2018.docx