HCPCS code T1025 – Intensive multidisciplinary services, per diem

Key takeaways

HCPCS code T1025 is a per diem code, not a per-visit code. One unit equals one calendar day of PPEC services.

T1025 is a Medicaid code only. Medicare does not recognize T-series codes and will deny any T1025 claim.

A physician-signed care plan and a daily attendance record are the two documents most frequently cited in PPEC audits.

The codes around T1025 bill on different units, so T1026 pays per hour and T1024 pays per encounter.

Pabau’s claims management software supports HCPCS code entry, Medicaid claim preparation, and auditable daily service documentation.

What is HCPCS code T1025?

HCPCS code T1025 is a Level II code billed per diem for intensive, extended multidisciplinary services. CMS defines those services as provided in a clinic setting to children with complex medical, physical, mental and psychosocial impairments. The code took effect on January 1, 2000 and remains valid for 2026 billing.

T1025 sits within the T-series of HCPCS Level II codes, the range T1000-T5999. The Centers for Medicare and Medicaid Services (CMS) maintains that range for use by state Medicaid agencies.

Unlike CPT codes or J-codes, T-series codes have no Medicare applicability. State Medicaid programs use them to pay for services the AMA’s CPT system does not describe.

What is a Prescribed Pediatric Extended Care (PPEC) facility?

A Prescribed Pediatric Extended Care (PPEC) facility is a licensed, medically supervised day program for children who are medically fragile or technology-dependent. These children need intensive nursing and therapeutic services during daytime hours. PPEC sits between home nursing care, which is often insufficient or unsustainable, and pediatric inpatient admission, which is clinically unnecessary for stable but complex patients.

Children who qualify typically have diagnoses such as bronchopulmonary dysplasia, cerebral palsy, spina bifida, tracheostomy dependency, or complex seizure disorders. The multidisciplinary team usually includes registered nurses, respiratory therapists, physical therapists, occupational therapists, speech-language pathologists, and social workers. All of them coordinate care under a physician’s direction.

• PPEC is not a day care center. Medicaid separates PPEC from standard child care, and the child must have documented medical necessity for this level of care.
• PPEC is not inpatient care. Children return home each evening, and T1025 covers the daytime program only.
• PPEC licensing is state-specific. Florida, Mississippi, Kentucky, and Texas have the most established PPEC Medicaid programs, but eligibility criteria and licensed facility counts vary by state.
• The clinic setting is part of the descriptor. Services must be delivered as a coordinated program at the facility, so individual therapy visits billed elsewhere are not T1025.

How per diem billing works

T1025 is billed per diem, meaning one unit of service equals one full calendar day of PPEC attendance. A child attending PPEC five days in a given week generates five units of T1025. Billing staff who default to per-visit logic submit one claim line per therapy session. That use of the code is incorrect and will trigger overpayment audits.

Per diem billing bundles every service delivered that day into a single daily rate. Fee-for-service billing instead links each billable event to a specific procedure. The T1025 claim reflects the child’s attendance, not a count of individual services.

• Claim form: CMS-1500 or 837P electronic transaction
• Units: One unit per calendar day of attendance (do not bill partial days as a fraction)
• Place of service: Typically POS 49 (independent clinic) or POS 99 (other unlisted facility), depending on state Medicaid guidance
• Modifiers: State-specific; some programs require a facility modifier. Confirm with the state Medicaid fee schedule before submitting.
• Revenue code: Not applicable on professional claims. It may apply on institutional UB-04 claims, depending on state billing rules.

Reimbursement rates and fee schedule

Each state’s Medicaid program sets the reimbursement rate for T1025, not CMS federally. No national Medicare fee schedule equivalent exists for T-series codes. States with mature PPEC programs publish explicit per diem rates in their Medicaid fee schedules. States without a recognized PPEC program may publish no rate at all.

Use the CMS Physician Fee Schedule lookup to confirm whether a national rate exists for HCPCS Level II codes. Then cross-reference the relevant state Medicaid agency portal for T1025-specific rates. State Medicaid usually returns an 835 remittance transaction that maps each T1025 claim line to the contracted daily rate.

Important: Specific dollar amounts change with each state’s annual Medicaid rate update. Verify current rates directly from the state Medicaid fee schedule before quoting reimbursement figures to a facility.

Which payers cover T1025?

T1025 is a Medicaid code. No Medicare coverage exists for T-series HCPCS codes, and any T1025 claim submitted to Medicare will be denied. Medicaid managed care organizations (MCOs) in a state with a PPEC program may cover T1025, though prior authorization rules and rates vary by plan. Verifying the child’s eligibility before each service period prevents the most common coverage-related denials.

Documentation requirements for a PPEC claim

Documentation is the area most frequently cited in PPEC audits. The code covers an entire day of intensive services. Payers therefore expect the record to substantiate the child’s medical necessity and the daily delivery of coordinated care. Incomplete documentation drives most retrospective claim denials and recoupment demands.

Structured digital forms for attendance and care-plan documentation reduce the risk of missing fields during an audit. Timestamped entries stored against the child’s record also make retrieval faster when a payer asks for proof.

• Physician order or referral: A signed physician order authorizing PPEC services, specifying the diagnosis and level of care required. It must be renewed on the state Medicaid schedule, often every 60 to 90 days.
• Individual care plan: A written, individualized care plan covering medical, nursing, therapy, and developmental goals. It must be dated, signed, and updated per state requirements.
• Eligibility and medical necessity documentation: Evidence that the child meets the state’s PPEC eligibility criteria, including the qualifying diagnosis and functional limitations.
• Daily attendance records: A dated record confirming the child was present for each day billed. This is the document most commonly missing in audits.
• Progress notes: Notes from nursing and therapy staff documenting services actually delivered during each billed day.
• Prior authorization: Where the Medicaid MCO requires it, written PA approval must be on file before services begin.

State Medicaid programs take medical billing compliance seriously for PPEC, given the high per diem cost of these services. Any discrepancy between the daily attendance record and the claim date of service is an automatic audit flag.

ICD-10 diagnosis codes used with T1025

Every T1025 claim must carry an ICD-10-CM diagnosis code that establishes medical necessity for the PPEC level of care. The diagnosis should reflect the child’s primary medically complex condition, not an incidental finding. Each code below comes from the ICD-10-CM code set and reflects a population PPEC facilities typically serve.

State Medicaid programs may restrict which ICD-10 codes qualify for T1025 coverage. Cross-reference diagnosis codes against the state’s published PPEC coverage policy before billing. The AAPC HCPCS code lookup includes crosswalk tools that help identify pairing restrictions.

Related HCPCS codes and the T-code crosswalk

Several T-series codes are used alongside or instead of T1025, and they do not share a billing unit. The grouping below shows which unit each one bills on, which is where most crosswalk errors start. The NLM Clinical Table Search API carries the current CMS description for every T-code.

Common billing errors and how to avoid them

T1025 claims are denied more often than most HCPCS codes, because coders unfamiliar with PPEC apply standard outpatient logic to a per diem program. The errors below repeat across a full month of billing, so each one compounds quickly.

• Billing multiple units for the same day. T1025 is one unit per calendar day. Submitting two units on a single date of service triggers an automatic edit, because the per diem rate already covers the full program day.
• Submitting to Medicare. T-codes are not Medicare-recognized. Any T1025 claim sent to a Medicare fiscal intermediary will deny, so confirm the payer type before claim generation.
• Missing or expired physician order. A lapsed order is the most common reason for denial on audit. Build a recurring reminder at the 60-day mark for any child whose order is approaching renewal.
• Billing T1025 for therapy-only days. A child who attends only for a scheduled speech therapy session may not qualify for the per diem code. Know your state’s policy on partial-day and therapy-only attendance.
• Failing to renew prior authorization. MCOs typically issue PA in 90-day or 180-day increments. Days that fall outside an approved period become non-billable retroactively, so track PA end dates in your billing system.
• Substituting T1026 for T1025. The two carry the same service wording, but T1026 is billed per hour. Check the state Medicaid provider manual before using either one.

Each claim line needs complete patient demographics, a valid NPI, and a diagnosis code that passes the state’s medical necessity criteria. Add T1025 as the procedure code only once those are in place.

How practice management software supports T1025 billing

PPEC facilities carry a documentation load that most practice management tools were not built to handle. Per diem billing needs daily attendance records tied to individual patient profiles, Medicaid-specific claim formats, and PA renewal tracking across a high-acuity pediatric caseload. Generic billing software treats every claim line as a fee-for-service encounter, which does not match how T1025 works.

Practice management software like Pabau handles HCPCS code entry, Medicaid claim preparation, and structured documentation for complex care settings. Pabau’s claims management software flags pending PA renewals and incomplete daily records before a claim batch is submitted. That gives a PPEC facility time to correct the record before the claim leaves, rather than after a recoupment demand arrives.

A superbill built from each child’s daily attendance record gives the facility a structured internal document that maps attendance to the T1025 claim line. It simplifies audit response and keeps the billing cycle traceable from service delivery to payment posting.

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Conclusion

Most PPEC facilities lose money on T1025 through record-keeping rather than coding. A physician order, a current care plan, and a signed attendance record have to line up for every day billed, for every child enrolled.

Build the weekly reconciliation habit before caseload volume grows. Catching one unmatched date of service each week costs a few minutes. Finding sixty of them during a retrospective audit puts months of payments at risk.

Pabau’s claims management platform supports the structured documentation and HCPCS billing workflows that PPEC facilities need. Book a demo to see how it handles Medicaid claim preparation for complex pediatric caseloads.

Continue your research

Want to understand the full revenue cycle? Revenue cycle management fundamentals explains how per diem billing fits into the cycle from eligibility to payment posting.

Concerned about claim denials? Denial codes in medical billing breaks down the most common denial reason codes and how to respond to each one.

Frequently asked questions