Colorado Physical Therapy Billing Rules: Medicaid, Workers' Comp, Direct Access

RuleColorado's Physical Therapy Practice Act lets a PT make "a physical therapy diagnosis within the physical therapist's scope of practice" (C.R.S. 12-285-108(2)). Every PT must carry liability insurance of at least $1 million per claim and $3 million per year, unless the employing corporation's policy meets those limits or a narrow exception applies (C.R.S. 12-285-118).

Our readingWe found no referral requirement and no visit or day cap anywhere in Article 285 of the 2024 statutes. That's our read of the statute, not a board opinion.

The catch is on the payer side. Health First Colorado still requires an order for every PT treatment service. In workers' comp, the ordering authorized treating provider (ATP) has to agree with any continuation or change to your plan (Rule 18-4(H)(1)(c)). Direct access gets the patient in the door. The order gets you paid.

RuleMembers get up to 48 units of PT and OT combined per rolling 12-month period before a prior authorization request (PAR) is required. Evaluations and orthotics don't count. The 12 months start when therapy starts, units come off the total from paid claims for that member no matter which provider billed them, and the claims system denies anything past the limit (HCPF Physical and Occupational Therapy Billing Manual).

That last part bites. Since 8 January 2026 the manual tells providers to check available units in the Provider Web Portal before each appointment, and warns the portal isn't a real-time count. If another clinic's claim lands first, your visit can be the one past 48.

The other rules behind most Colorado Medicaid PT denials, all from the same HCPF manual:

• Treatment must be ordered by a physician, physician assistant or advanced practice nurse, and start within 28 days of the order.
• Since 1 July 2024 the ordering provider's NPI must be on the claim: box 17b on paper, loop 2420 electronically. That provider must be enrolled with Health First Colorado. If the NPI is missing, the claim denies, and paid claims without a valid one can be recovered.
• PTAs can't enroll. Bill their services under the supervising PT's NPI, and keep records showing the PTA did the work.
• The plan of care must be reviewed and signed by the member's physician or other licensed practitioner every 90 days.
• Modifiers: GP plus 97 for rehabilitative PT, GP plus 96 for habilitative PT. The claim must carry the same modifiers as the PAR, in the same order.
• Progress notes sent with a PAR can't be more than 60 days old.
• Members can't be billed for services denied for lack of information.

Our readingThe manual says that when a provider fails to request a PAR past 48 units, those services aren't treated as non-covered. So the miss is the practice's to absorb, not something to pass on to the member.

RuleFor 2026, the Division of Workers' Compensation pays physical medicine and rehabilitation at $48.53 per RVU, times the non-facility total RVUs in Medicare's April 2025 relative value file (Rule 18, effective 1 January 2026, linked from the DOWC fee schedule page). The Rule 18 formula has no geographic factor, so the rate is the same statewide.

Our math, not a published feeWorkers' comp: non-facility total RVUs from CMS's April 2025 RVU25B file (0.89, 0.99, 0.84, 1.07) times $48.53. Medicare: CMS's 2026 relative values from the CMS 2026 file, times Colorado's 2026 GPCIs (1.012, 1.064, 0.781) from the CMS localities file, times $33.4009. Full fee schedule amounts for one unit, before any payment reductions.

The limits that cost Colorado clinics money (Rule 18-4(H)):

• No more than two modality codes and no more than 60 minutes or four units of procedure codes per visit, per discipline, per day, unless medical necessity is documented and prior authorization is obtained.
• GP on all PT. Add CQ when a PTA provides the service in whole or in part, meaning past the CPT midpoint. CQ services pay 85% of the fee schedule. The 8-minute rule calculator shows CPT midpoint units next to Medicare units.
• Document the time spent on each service and the start and end time of every session.
• The prescribing provider re-evaluates the worker within 30 calendar days of starting PT, and at least monthly after that.
• Bill a re-evaluation only for an unexpected change, new clinical findings, or no response to the plan. Never for a progress note.
• The Rehabilitation Communication Form (WC 196, DoWC Z0817, $15.92) can go to the physician every two weeks for the first six weeks, then every four weeks.

RuleFrom Rule 16: bills are due within 120 days of the date of service, unless extenuating circumstances exist. Timely filing issues become final 10 months after the date of service.

Proof is where clinics lose these. For electronic bills, only the payer's acknowledgment that the claim was accepted counts. A rejected claim or a clearinghouse report doesn't. For paper bills, keep a signed certificate of mailing, a fax confirmation, or a certified mail receipt showing when the payer got it.

Since 1 January 2026, any provider sending 25 or more workers' comp bills a month must bill electronically (Rule 16-8-1), through its own software or a clearinghouse, and process the payer's acceptance or rejection acknowledgments. Payers other than self-insured employers must acknowledge a complete electronic bill within two business days.

RuleColorado Part B claims go to Novitas Solutions, the contractor for Jurisdiction H (CMS). The whole state is one Medicare payment area (CMS locality key), so a unit of 97110 pays the same $30.04 in Denver, Durango and Grand Junction.

Not under the PT practice act, as we read it. Payers are another matter: Health First Colorado requires an order from a physician, physician assistant or advanced practice nurse, with the ordering NPI on the claim, and in workers' comp the authorized treating provider has to agree with your plan (HCPF manual, Rule 18-4(H)(1)(c)).

It counts units, not visits: 48 units of PT and OT combined per rolling 12 months, across every provider the member sees. Evaluations and orthotics don't count toward the 48 (HCPF manual).

Up to 60 minutes or four units of procedure codes, plus no more than two modality codes, per visit, per discipline, per day. More needs documented medical necessity and prior authorization (Rule 18-4(H)(4)).

120 days from the date of service, under DOWC Rule 16-8-2. Keep the payer's acceptance acknowledgment, because a clearinghouse report doesn't prove timely filing.

Yes, if you send 25 or more workers' comp bills a month. Since 1 January 2026, those providers need billing software or a clearinghouse that exchanges bills in the adopted electronic standard (Rule 16-8-1).

• Colorado Revised Statutes 2024, Title 12 (Article 285, Physical Therapy Practice Act)
• HCPF Physical and Occupational Therapy Billing Manual (revised 20 July 2026)
• DOWC Fee Schedule (Rule 18) page and Rule 18, effective 1 January 2026
• DOWC Rule 16, Utilization Standards
• CMS RVU25B (April 2025 relative value file)
• CMS: A/B MAC Jurisdiction H and Medicare locality key
• CMS: 2026 GPCIs by locality and 2026 relative values