California, Connecticut, Delaware, Florida, Georgia, Illinois, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Ohio, South Carolina, Texas, Vermont, Virginia, West Virginia

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

This LCD provides guidelines for many physical medicine and rehabilitation services. This LCD does not address all services, including but not limited to: services related to wound care, incontinence, swallowing problems / dysphagia, other speech-language pathology services, VitalStim therapy, fabrication and application of splints and strapping, biofeedback training, muscle and range of motion testing, and cardiac and pulmonary rehabilitation programs.

Physical medicine and rehabilitative services are designed to improve or restore physical functioning following disease, injury or loss of a body part. Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to characterize individuals with impairments, functional limitations and disabilities. Impairments, functional limitations and disabilities thus identified are then addressed by the design and implementation of therapeutic interventions tailored to the specific needs of the individual patient. The specific interventions most commonly utilized are exercise, heat, cold, electricity, ultraviolet light, ultrasound, hydrotherapy, manual therapy and massage to improve circulation, strengthen muscles, maintain or restore motion, and train or retrain an individual to perform the activities of daily living.

Physical medicine and rehabilitation services are covered when performed with the expectation of restoring the patient's level of function which has been lost or reduced by injury or illness. Therapy performed repetitively to maintain a level of function is not eligible for reimbursement.

A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. During the last visits for rehabilitative treatment, it may be reasonable and medically necessary for the clinician to develop a maintenance program, and instruct the patient, family member(s) or caregiver(s) in carrying out the maintenance program.

Visual Rehabilitation Services

A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient's level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical.

Vision impairment ranging from low vision to total blindness may result from a primary eye diagnosis, such as macular degeneration, retinitis pigmentosa, or glaucoma, or as a condition secondary to another primary diagnosis, such as diabetes mellitus or acquired immune deficiency syndrome (AIDS).

The purpose of rehabilitative therapy is to maximize the use of residual vision and provide patients with many practical adaptations for activities of daily living. In doing so, it builds the confidence that is necessary for ongoing creative problem solving. Rehabilitation appears to be more effective if it is started as soon as functional visual difficulties are identified.

Sessions are generally conducted over a three month period of time with intervals appropriate to the patient's rehabilitative needs. If additional sessions are necessary, medical record documentation must indicate the need for the additional sessions.

The level of vision impairment is defined as:

moderate = best corrected visual acuity is less than 20/60

severe (legal blindness) = best corrected visual acuity is less than 20/160, or
visual field is 20 degrees or less

profound (moderate blindness) = best corrected visual acuity is less than 20/400, or visual field is 10 degrees or less

near-total (severe blindness) = best corrected visual acuity is less than 20/1000, or visual field is 5 degrees or less

total (total blindness) = no light perception.

EVALUATIONS AND RE-EVALUATIONS (CPT 97001-97004)

Medicare provides reimbursement for an evaluation that is reasonable and necessary for the clinician to determine if there is an expectation that the services will be appropriate for the patient’s condition. The evaluation of a patient's level of function is focused on identifying what the patient wants and needs to do, and on identifying those factors that help or hinder the performance of those activities. During the first patient contact, the clinician evaluates and documents:
• A diagnosis (where allowed) and description of the specific problem to be evaluated and/or treated. This should include the specific body part(s) evaluated. Include all conditions and complexities that may impact the treatment. A description might include, for example, the pre-morbid function, date of onset, and current function;
• Objective measurements, preferably standardized patient assessment instruments and/or outcomes measurement tools related to current functional status, when these are available and appropriate to the condition being evaluated;
• Clinician’s clinical judgments or subjective impressions that describe the current functional status of the condition being evaluated, when they provide further information to supplement measurement tools; and
• A determination that treatment is not needed, or, if treatment is needed a prognosis for return to pre-morbid condition or maximum expected condition with expected time frame and a plan of care.

A re-evaluation is the re-assessment of the patient’s performance and goals, after an intervention plan has been instituted, in order to determine the type and amount of change in treatments if needed. Re-evaluation requires the same professional skill as evaluation. Continuous assessment of the patient’s progress is a component of ongoing therapy services, and is not a re-evaluation. A re-evaluation is not a routine, recurring service but is focused on evaluation of progress toward current goals, making a professional judgment about continued care, modifying goals and/or treatment or terminating services.


MODALITIES

Multiple therapy modalities may be reasonable and necessary in many clinical situations. Documentation in the patient’s medical record should support the use of multiple modalities as contributing to the patient’s progress and restoration of function, and as per the plan of care. When more than one modality is used during an encounter, whether supervised or constant attendance, or any combination, each modality provided should be reported and reflected in the documentation. This documentation must be made available to Medicare upon request.

Modalities are categorized as either supervised or constant attendance.

Supervised Modalities (CPT 97010-97028)

Supervised modalities are considered to be the application of a modality that does not require direct (one-on-one) patient contact by the provider. There is no time component that describes supervised codes. The code is reported without regard to the length of time spent performing the service. These services are to be billed only once per encounter regardless of the number of areas treated.

Hot or cold packs therapy (CPT 97010)

Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm, and reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs are used for sub acute or chronic painful conditions.

Heat or cold treatments ordinarily do not require the skills of a qualified clinician. However, the skills, knowledge and judgment of a qualified clinician may be required while providing these treatments in specific cases where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications. Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a qualified clinician.

The application of this modality is considered to be an integral part of a service or visit by CMS. Therefore the service for the application of hot or cold packs (97010) is a status B (bundled) code on the Medicare Fee Schedule Data Base (MFSDB). Separate payment is not allowed for this service.

Mechanical traction therapy (CPT code 97012)

Mechanical traction is the force used to create a degree of tension on soft tissues and/or allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time) and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction are intermittent or static (describing the length of time traction is applied), or autotraction (use of the body’s own weight to create the force).

Traction is generally used for joints, especially of the lumbar or cervical spine, with the expectation of relieving pain in or originating from those areas, or increasing the range of motion of the joint. Specific indications for the use of mechanical traction include but are not limited to cervical and/or lumbar radiculopathy, and back disorders such as disc herniation, lumbago, and sciatica. This modality is generally used in conjunction with therapeutic procedures and not as an isolated treatment.

Electrical stimulation other than wound (HCPCS code G0283)

Unattended electrical stimulation means the patient is positioned and the appropriate type of stimulation is applied to an area over a specific period of time. HCPCS code G0283 should be used for unattended electrical stimulation, to one or more areas for indications other than wound care. (Note: CPT code 97014 is considered invalid for Medicare effective 01/01/03.)

Refer to the Constant Attendance Modalities section of this policy under CPT code 97032 for additional information pertaining to electrical stimulation.


Vasopneumatic devices (CPT code 97016)

The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity, for the purpose of reducing edema. Specific indications for the use of vasopneumatic devices include the reduction of edema after acute injury, and the treatment of lymphedema of an extremity.

When treating lymphedema with this device, the sessions are for the primary purpose of education on the use of the lymphedema pump at home. The education typically is completed in no more than three (3) visits. Further treatment of lymphedema by a qualified clinician, after the educational visits, is generally not reasonable and necessary unless the patient presents with a condition or status requiring the skills and knowledge base of a qualified clinician.

Paraffin bath therapy and Whirlpool therapy

Heat treatments and baths of this type typically do not require the skills of a qualified clinician. However, the skills, knowledge and judgment of a qualified clinician might be required in providing such treatments or baths in specific cases where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications.

Paraffin bath therapy (CPT code 97018)

Paraffin bath therapy is a wax treatment used to apply superficial heat for a sustained duration for the effects on underlying tissues. Paraffin baths are primarily used for pain relief in joint problems of the hands or feet.

One or two visits are usually sufficient to educate the patient in home use and to evaluate the effectiveness of the treatment. Continued treatment may require supportive documentation of medical necessity.

Whirlpool therapy (CPT Code 97022)

Whirlpool therapy involves the use of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.

Clinician supervision of whirlpool therapy may be medically necessary if the patient’s condition is complicated by a circulatory deficiency, areas of desensitization, or exfoliative skin impairments. It is necessary to have clinician supervision if the patient has a documented open wound that is draining, has a foul odor, or evidence of necrotic tissue or has a documented need for wound debridement or bandage removal.

Generally, whirlpool treatments are not performed more than 12 times in one month. Services beyond this number may require documentation supporting the medical necessity of continued whirlpool treatments. It is not medically necessary to have more than one form of hydrotherapy during a visit (e.g., CPT codes 97022, 97036 or 97113 cannot be billed together).

Diathermy treatment (CPT code 97024)

Diathermy is an appropriate modality for heating skeletal muscle. Heating is accomplished without physical contact between the modality and the skin, therefore it can be used even if skin is abraded, as long as there is no significant edema. The use of diathermy is considered reasonable and necessary for the delivery of heat to deep tissues such as skeletal muscle and joints for the reduction of pain, joint stiffness, and muscle spasm.

High energy pulsed wave diathermy machines have been determined to produce the same therapeutic benefit as standard diathermy; therefore, these treatments are considered reasonable and necessary for the same indications as standard diathermy.

Diathermy is not considered reasonable and necessary for the treatment of asthma, bronchitis, or any other pulmonary condition.

The medical records must clearly document the clinical rationale for choosing this modality over the more commonly used treatments.

Infrared therapy (CPT code 97026)

Infrared therapy is a modality that uses light and heat to raise the tissue temperature 5 to 10 degrees centigrade in the area of application. This thermal modality is commonly used to provide analgesia, relieve muscle spasm, cause vasodilatation, and reduce inflammation and edema. It is usually used in conjunction with other therapeutic procedures and rarely with other thermal modalities.

Treatments of this type ordinarily do not require the skills of a qualified clinician. However, the skills, knowledge and judgment of a qualified clinician may be required in the giving of such treatment in a particular case, for example, where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications. Documentation in the medical record must include infrared therapy as part of the plan of care and must clearly justify the medical necessity of the treatment and clinician involvement.

These nationally non-covered indications are effective for services performed on and after October 24, 2006: The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues.

Ultraviolet therapy (CPT code 97028)

Ultraviolet therapy is a form of radiant energy that uses light rays with wavelengths beyond the violet end of the visual spectrum. The ultraviolet therapy modality is used to stimulate a variety of chemical reactions in the skin and mucous membranes. It is used for the treatment of psoriasis and other skin conditions and in assisting the healing process of open wounds.

Documentation in the patient’s medical record must include ultraviolet therapy treatment as a part of the plan of care and must clearly justify the medical necessity of the treatments.

Constant Attendance Modalities (CPT codes 97032-97039)

Constant attendance modalities are considered to be the application of a modality that requires direct (one-on-one) patient contact by the provider. Direct one-on-one contact requires that the provider maintain visual, verbal, and/or manual contact with the patient throughout the procedure. The time frames indicated for the constant attendance modalities describe the total time (i.e., pre-service, intra-service and post-service time) spent performing this modality. Documentation in the medical record for constant attendance modalities must ascertain that the total number of minutes of treatment for services represented by timed codes is consistent with the number of units billed for those services.

Electrical stimulation (CPT code 97032)

Electrical stimulation is addressed in several CMS NCDs found in the IOM Pub. 100-03, Medicare National Coverage Determinations Manual. Specific guidance on use of electrical nerve stimulators for the treatment of chronic intractable pain can be found in the NCDs.

Examples of specific types of either unattended or attended electrical stimulation include but are not limited to: Transcutaneous electrical nerve stimulation (TENS), Neuro-muscular stimulation (NMS), High voltage pulsed current (HVPC), also called electrogalvanic stimulation, and Microcutaneous electrical stimulation (MENS) or microcurrent.

Examples of specific types of constant attendance electrical stimulation, in addition to those listed above, include but are not limited to: Muscle stimulation (M-Stim), Interferential current/medium current (IFC), and Functional Electrical Stimulation (FES).

Electrical stimulation may be considered reasonable and necessary during the initial phase of rehabilitation treatment when there is an expectation of improvement in function. Electrical stimulation is generally utilized with other therapeutic procedures, such as therapeutic exercises, to affect continued improvement.

Electrical stimulation is indicated for the patient with pain, muscle spasm, or spasticity; for the patient who has a documented reduction in the ability to contract muscles; or who has diminished muscle contraction strength, with or without dependent peripheral edema. It is indicated for a patient who has a condition that requires an educational program for self-stimulation of denervated muscle or a condition that requires muscle reeducation involving a training program (i.e., functional electrical stimulation).

Typically, electrical stimulation treatment consists of up to twelve (12) sessions per month when used as adjunctive therapy or for muscle retraining. Services beyond twelve (12) sessions per month may require clear documentation supporting the medical necessity of continued treatments.

Electrical stimulation is also used for the patient who is undergoing treatment for disuse atrophy using a specific type of neuromuscular electrical stimulator (NMES) which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. As described in the NCD, coverage of NMES to treat muscle atrophy is limited to the treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse atrophy (e.g., post casting or splinting of a limb, contracture due to soft tissue scarring as in burn lesions, and hip replacement surgery (until orthotic training begins).

Coverage for the use of NMES/FES for walking in spinal cord injury (SCI) patients is also described in the NCD for Neuromuscular Electrical Stimulator. Per the NCD, coverage is limited to SCI patients for walking, who have completed a training program which consists of at least 32 physical therapy sessions with the device over a period of three months. Additional specific indications and limitations of coverage are found in the Medicare National Coverage Determinations Manual, IOM Pub. 100-03, section 160.12.

Electric current therapy (CPT code 97033)

Iontophoresis is an intervention that uses the properties of electricity to introduce ions of soluble salts and medications (such as NSAIDS and/or analgesics) into tissue by means of an electric current. This modality is non-invasive and utilizes polarity differences to push the medication across the cell membranes.

This modality is used to reduce pain and edema caused by an inflammatory process such as tendonitis, bursitis, plantar fasciitis and lateral epicondylitis. Usually 3-6 treatments are necessary to assess the effectiveness of this modality.

Contrast bath therapy (CPT code 97034)

Contrast bath therapy is the alternate immersion of a body part in hot water (98-112 degrees Fahrenheit) and cold water (60-75 degrees Fahrenheit). This special form of therapeutic heat and cold is commonly applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold.

Specific indications for the use of contrast baths include but are not limited to the patient having rheumatoid arthritis, other inflammatory arthritis, reflex sympathetic dystrophy, or a sprain or strain resulting from an acute injury.

Heat treatments and baths of this type ordinarily do not require the skills of a qualified clinician. However, the skills, knowledge and judgment of a qualified clinician might be required in the giving of such treatments or baths in a particular case, for example when the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fracture or other complications.

Ultrasound therapy (CPT code 97035)

Therapeutic ultrasound is a deep heat modality. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of ultrasound, as much as 30% more. Because of the increased extensibility ultrasound produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense heating, it is an ideal modality for increasing mobility in those tissues with restricted range of motion.

The application of ultrasound is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and to increase the flexibility of muscles, tendons and ligaments.

Specific indications for the use of ultrasound application include but are not limited to the patient having neuromas, symptomatic soft tissue calcification or tightened structures limiting joint motion that require an increase in extensibility.

Ultrasound application is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.

Ultrasound treatments are typically applied three (3) times weekly for four (4) weeks. It is generally not medically necessary for a patient to receive more than twelve (12) visits for ultrasound treatments. Services beyond this number may require clear documentation supporting the medical necessity of continued ultrasound treatments.

Hydrotherapy (CPT code 97036)

This modality involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions. Physician or therapist one-on-one supervision of this modality is required. Documentation in the medical record must clearly note that the skills of a qualified clinician were necessary in order to treat the patient with this modality.

Typical treatment duration is 3-4 times weekly for 2-4 weeks. Services beyond this number may require documentation supporting the medical necessity of continued hydrotherapy (e.g., Hubbard tank) treatments. It is not medically necessary to have more than one form of hydrotherapy during a visit (e.g., CPT codes 97022, 97036 or 97113 cannot be billed together).

Physical therapy treatment (CPT code 97039)

For all claims submitted with this unlisted modality code, a complete narrative description (detailing the type of modality, time and one-on-one provider/patient contact) and the treatment plan supporting the medical necessity of the service must be submitted with the claim.

THERAPEUTIC PROCEDURES (CPT codes 97110-97546)

Therapeutic procedures are treatments that attempt to reduce impairments and improve function through the application of clinical skills and/or services. Use of these procedures requires that the therapist have direct (one-on-one) patient contact. Common components included as part of the therapeutic procedures include chart reviews for treatment, set up of activities and the equipment area, and review of previous documentation as needed. Also included is communication with other health care professionals, discussions with family, and calls to the referring physician for additional information or clarification. Subsequent to providing the therapeutic service, the treatment is recorded, and typically the progress is documented.

Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals must be documented in the treatment plan, and affected by the use of each of these procedures, in order to define whether these procedures are reasonable and necessary. Therefore, since only one, or a combination of more than one of these modalities may be used in the treatment plan, documentation must support the use of each treatment or modality as it relates to a specific therapeutic goal.

Services provided concurrently by a physician, physical therapist and an occupational therapist may be covered if separate and distinct goals are documented in the treatment plans.

Lymphedema

When therapeutic exercises (CPT 97110), massage therapy (CPT 97124), and/or manual therapy (CPT 97140) are used for the treatment of lymphedema, the following also applies. This type of lymphedema treatment is designed to transfer the responsibility of the care from the clinic, hospital, or doctor, to home care by the patient, patient family or patient caregiver. It is expected that physician/physical therapist treatment would only last for one to two weeks, depending on the progress of the therapy. After that time, there should have been enough teaching and instruction that the care could be continued by the patient or patient caregiver in the home setting. The maximum benefits of treatment are not expedited unless the patient continues treatment at home. It was noted in recent literature that manual lymphedema therapy is effective when performed for one hour three times per week.

It is conceivable that a patient may require "tune up" lymphedema decongestant massages after minor events (i.e., local infection, trauma, therapeutic injections). With these subsequent treatments, the same criteria as that of initial treatment must be met.

The coverage of the massage therapy would only be allowed for lymphedema if the following conditions have been met: there is a physician documented diagnosis of lymphedema; the patient is symptomatic for lymphedema, with limitation of function; the patient or patient caregiver has the ability to understand and comply with home care continuation of treatment regimen; the services are being performed by a physician and/or licensed physical therapist who has received specialized training in this form of treatment.


Therapeutic exercises (CPT code 97110)

Therapeutic exercise incorporates rehabilitation principles related to strengthening, endurance, flexibility, and range of motion to one or more areas of the body. Therapeutic exercise may be performed with a patient either actively, actively assisted, or passively participating. Examples of these exercises include treadmill (for endurance), isokinetic exercise (for range of motion), lumbar stabilization exercises (for flexibility and/or trunk strengthening), and gymnastic ball (for stretching and strengthening).

Therapeutic exercise is considered reasonable and necessary if the patient is having weakness, pain, contracture, stiffness (secondary to coordination deficits, spasticity, or injury), abnormal posture, muscle imbalance or the patient needs to improve mobility, stretching, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance. At least one of these conditions must be present and documented in the medical records. Documentation for therapeutic exercise must show objective functional loss of joint motion, strength, mobility (e.g., degrees of motion, strength grades, and levels of assistance) and endurance.

Neuromuscular reeducation (CPT code 97112)

This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, motor skill, and proprioception. Examples of these treatments include proprioceptive neuromuscular facilitation (PNF), Feldenkrais, Bobath, use of Biomechanical Ankle Platform System (BAPS) boards, and desensitization techniques.

Neuromuscular reeducation may be reasonable and necessary for impairments, which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity).

The documentation in the medical records must clearly identify the need for these treatments, be part of the plan of care and reflect the patient’s response to treatments.

Aquatic therapy/exercises (CPT code 97113)

Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility. This requires direct (one-on-one) patient contact. This code is to be used for any exercise performed in a water environment.

This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and medically necessary for a loss or restriction of joint motion, strength, mobility, or function, which has resulted from a specific disease or injury.

Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees or motion, strength grades, levels of assistance) and reflect the medical necessity of the treatment. Other forms of exercise therapy may be medically necessary in addition to aquatic therapy when the patient cannot perform land based exercises effectively to treat his/her condition without first undergoing the aquatic therapy, or when aquatic therapy facilitates progress to land based exercise or increased function.

DO NOT CODE the water modality (e.g. hydrotherapy / Hubbard tank, whirlpool), AND the type of therapeutic exercise (e.g. neuromuscular reeducation) SEPARATELY. Code ONLY the aquatic therapy with therapeutic exercise (97113). This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers). It is not medically necessary to have more than one form of hydrotherapy during a visit (e.g., CPT codes 97022, 97036 or 97113 cannot be billed together).


Gait training therapy (CPT code 97116)

Gait training is the training of the biomechanical and kinesiological components of walking, including balance, cadence, symmetry, motor control, speed, energy efficiency, and endurance. The phases of gait include the stance phase, the swing phase, and the double support phase. This procedure may be reasonable and necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.

Specific indications for gait training include but are not limited to:

-the patient having suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation.
-the patient having recently suffered a musculoskeletal trauma, requiring ambulating reeducation
-the patient having a chronic, progressively debilitating condition for which safe ambulation has recently become a concern
-the patient having had an injury or condition that requires instruction in the use of an assistive device, e.g., walker, crutches, or cane
-the patient having been fitted with a brace/lower limb prosthesis and requires instruction in ambulation
-the patient having a condition that requires training in stairs/steps or chair transfer in addition to general ambulation

Gait training is not considered reasonable and necessary when the patient’s walking ability is not expected to improve.

Massage therapy (CPT code 97124)

Massage, which is designed to restore muscle function, reduce edema, improve joint motion, or relieve muscle spasm, may be medically necessary as adjunctive treatment to another therapeutic procedure on the same day.

Massage therapy, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least one of the following conditions is present and documented:

-paralyzed musculature contributing to impaired circulation
-sensitivity of tissues to pressure
-tight muscles resulting in shortening and/or spasticity of affected
muscles
-abnormal adherence of tissue to surrounding tissues
-relaxation required in preparation for neuromuscular re-education or
therapeutic exercise
-contractures and decreased range of motion
- lymphedema

Physical medicine procedure (CPT 97139)

For all claims submitted with an unlisted procedure code, a complete narrative description (detailing the service or procedure being performed) and the treatment plan supporting the medical necessity of the service or procedure must be submitted with the claim.

Manual therapy (CPT code 97140)

Manual therapy techniques consist of, but are not limited to, connective tissue massage, joint mobilization and manipulation, manual lymphatic drainage, manual traction, passive range of motion, soft tissue mobilization and manipulation, and therapeutic massage. As the code descriptor states, "manual," providers use their hands to administer these techniques. Therefore, code 97140 describes "hands-on" therapy techniques.

Typically, the goals of manual therapy are to modulate pain, increase joint range of motion, and reduce or eliminate soft tissue swelling, inflammation, or restriction. These techniques also induce relaxation and improve contractile and noncontractile tissue extensibility.

Manual therapy techniques may be performed on individuals with symptoms that may include a limited range of motion, muscle spasm, pain, scar tissue or contracted tissue, and/or soft tissue swelling, or inflammation.

1. Manual traction

This procedure may be considered reasonable and necessary for cervical radiculopathy and cervicalgia.

2. Joint mobilization (peripheral or spinal)

This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

3. Myofascial release/soft tissue mobilization, one or more regions

This procedure may be medically necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, or stretching of shortened muscular or connective tissue. This procedure may be medically necessary as an adjunct to other therapeutic procedures such as 97110, 97112, and 97530.

4. Manipulation

This procedure may be medically necessary for treatment of painful spasm or restricted motion of soft tissues. It may also be used as an adjunct to other therapeutic procedures such as 97110, 97112, and 97530.

Group therapeutic procedures (CPT code 97150)

Group therapy procedures involve the constant attention of the clinician but by definition do not require one-on-one patient contact by the clinician. Constant attention is required because it is not possible for the clinician to provide simultaneous one-on-one patient contact in a group setting. CPT code 97150 should be reported for each group member receiving a type of therapeutic modality when the therapist is working with several patients at the same time, whether “on land” or in a water environment / pool. The patients do not need to be receiving the same type of therapeutic modality.

The specific type of therapy provided (CPT codes 97110-97139) should NOT be reported in addition to the group therapy code. The individual therapy codes (CPT codes 97110-97139) should be reported when the clinician is providing therapy to only one patient.

The ICD-9 codes that are applicable to the individual patient should be billed with the CPT 97150. These ICD-9 codes will identify the condition for which the individual patient received rehabilitation services, and the 97150 will identify that the service was provided under the constant attention of the clinician in a group setting.

Documentation in the medical records must clearly identify that the therapy was medically necessary and performed by the clinician in a group setting (two or more individuals).

Therapeutic activities (CPT code 97530)

Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involves movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a clinician and are designed to address a specific functional need of the patient.

In order for therapeutic activities to be covered, all of the following requirements must be met:

-The patient has a condition for which therapeutic activities can reasonably be expected to restore or improve functioning; and
-The patient’s condition is such that he/she is unable to perform therapeutic activities except under the direct supervision of a clinician and
-There is a clear correlation between the type of exercise performed and the patient’s underlying functional deficit(s) for which the therapeutic activities were prescribed.

Therapeutic activities may be medically necessary when the professional skills of a clinician are required, and the activity is designed to address a specific need of the patient. These dynamic activities must be part of a documented treatment plan and intended to result in a specific outcome.

Cognitive skills development (CPT code 97532)

This code describes interventions used to enhance cognitive skills, (e.g., attention, memory, problem solving) with direct (one-on-one) patient contact by the clinician. It may be medically necessary for patients with acquired cognitive impairments from head trauma, acute neurological events (including cerebrovascular accidents), or other neurological disease.

As stated earlier, physical medicine and rehabilitation services are covered when performed with the expectation of restoring the patient's level of function which has been lost or reduced by injury or illness. When used in the setting of generally chronic progressive cognitive disorders, there must be a potential for restoration or improvement. Therapy performed repetitively to maintain a level of function is not eligible for reimbursement.

Sensory integrative techniques (CPT code 97533)

This activity focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands, with direct (one-on-one) patient contact by the clinician. When a patient has a deficit in processing input from a sensory system (e.g., vestibular, proprioceptive, tactile), it may decrease the patient’s ability to make adaptive sensory, motor, and behavioral responses to environmental demands.

Self care management training (CPT code 97535)

This training includes activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment, direct one-on-one contact by the clinician. The patient must have a condition for which training in activities of daily living is reasonable and necessary, and such training must be reasonably expected to restore or improve the functioning of the patient. The patient and/or caregiver must have the capacity to learn from instructions.

This procedure is reasonable and necessary only when it requires the skills of a clinician, is designed to address specific needs of the patient, and is part of an active treatment plan directed at a specific outcome. Documentation must relate the training to expected functional goals that are attainable by the patient.

Services provided concurrently by clinicians of different types, e.g., physical therapists and occupational therapists, may be covered if separate and distinct goals are documented in the treatment plans.

Community/work reintegration (CPT code 97537)

Community/work reintegration training includes shopping, transportation, money management, a vocational activities and/or work environment/modification analysis, work task analysis, and direct one-on-one contact by the provider.

Community reintegration procedures for the patient are reasonable and necessary only when they require the specific skills of a clinician, are designed to address specific needs of the patient, and are part of an active treatment plan directed at a specific outcome. The treatment plan may be aimed at improving or restoring specific functions that were impaired by an identified illness or injury, and when the expected outcomes, that are attainable by the patient, are specified in the plan. Generally speaking, physical medicine and rehabilitative services are not required to effect improvement or restoration of function where a patient suffers a temporary loss or reduction of function which could be expected to spontaneously improve as the patient gradually resumes normal activities.

Physical medicine and rehabilitative services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1)(A) of the Social Security Act.

Wheelchair management training (CPT code 97542)

This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning, positioning supplies, and wheel chair modifications, to avoid pressure points, contractures, and other medical complications. The patient and/or caregiver must have the capacity to learn from instructions.

This procedure is reasonable and necessary only when it requires the skills of a clinician, is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific goal. When billing 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient and/or caregiver.

Typically, three (3) to four (4) sessions should be sufficient to teach the patient and/or caregiver these skills unless the patient is severely impaired or presents with another condition requiring additional treatment sessions. Subsequent visits may be occasionally necessary for re-evaluation and modification of the wheelchair management and propulsion training in patients with progressive neurologic disorders such as ALS, MS or Parkinson’s disease. Documentation in the medical record must justify the medical necessity for an unusual frequency or duration of training sessions.

Work hardening (CPT code 97545) and Work hardening add-on (CPT code 97546)

These services relate solely to specific work skills. They will be denied as not medically necessary for the diagnosis or treatment of illness or injury.

TESTS AND MEASUREMENTS (CPT codes 97750-97755)

Physical performance test or measurement (CPT code 97750)

The physical performance test or measurement may be used to provide objective documentation of a patient’s condition or status that requires him/her to receive physical medicine and rehabilitative services. (Examples of this type of test include isokinetic testing, functional capacity evaluation, functional capacity wheeled mobility evaluation, and Tinetti.) The physical performance test or measurements provide additional information for the therapist to develop or change the plan or care properly. These tests and measurements are over and above the typical evaluation services performed. This code is reported by the time spent providing the service.

This testing may be medically necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific treatment plan, or to determine a patient’s functional capacity.

There must be written evidence documenting the problem requiring the test, the specific test performed and a measurement report. This report should clearly indicate a description of the test that was performed, the purpose for the test, the outcome of the test, and how the information affects the treatment plan. This code varies from CPT codes 97001-97004 in that it requires a separate report from other evaluations that may be done.

Assistive technology assessment (CPT 97755)

This code is used to represent the provider’s assessment of the interface between the patient and technology. The patient’s voluntary motion (e.g. oral motor strength, head/neck range of motion and strength, ocular motor control, quality of voice output and the patient’s ability to use the accessibility components and systems) are identified and assessed. Multiple systems/components are tested to determine optimal interface between patient and technology applications. Appropriateness of commercial (off the shelf) components or systems is determined. The need for modification of commercial components/systems is assessed. Custom components/systems are designed as needed for the patient.

Environmental constraints including home, work, and transportation are evaluated. The findings of the patient, technology and the environment are integrated to determine and design modifications to the existing environment or technology to assure the patient’s optimal functioning.

Procedure code 97755 requires direct one-on-one contact by the provider and is to be reported for each fifteen minutes of assessment. This service must be ordered by a physician and performed by a clinician. For Medicare reimbursement this service is not covered if provided by a therapy assistant. In order to bill this code the medical records must clearly contain the provider’s written report of the assessment, which must include all of the following:

-The goal of the assessment;
-The technology/component/system involved;
-A description of the process involved in assessing the patient’s response;
-The outcome of the assessment; and
-Documentation of how this information affects the treatment plan.

Documentation of assistive technology assessment must be available to Medicare upon request.

ORTHOTIC MANAGEMENT AND PROSTHETIC MANAGEMENT (CPT codes 97760-97762)

Orthotic training (CPT code 97760)

Orthotic training includes the fitting and training of the patient who requires orthotics.  This service includes assessment of the patient and determination of the most appropriate orthotic; design and fabrication of the orthotic; fitting and patient training required to properly use the orthotic device.

This procedure may be considered reasonable and necessary if there is an indication for reeducation, and the functional use of the orthotic is documented. The patient or caregiver must be capable of being trained to use the particular device prescribed in an appropriate manner. In some cases the patient may not be able to perform this function, but a responsible individual can be trained about the use of the device.

The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training (CPT code 97116) or self-care/home management training (CPT code 97535).

Usually less than 30 minutes is necessary for static orthotics training. In some cases, dynamic training may require additional time. Documentation supporting the medical necessity of the additional time must be present in the medical records. Typically, orthotic training can be completed in three (3) visits, but based on patient condition/status, may require additional visits. In addition, subsequent visits may be necessary for re-evaluation or modification of the orthotic and/or program.

Prosthetic training (CPT code 97761)

Prosthetic training is the professional instruction necessary for a patient to properly use an artificial device that has been developed to replace a missing body part. This procedure may be considered reasonable and necessary if there is an indication for education on the application of the prosthesis, the prosthesis is in the home and the functional use of the prosthetic is documented.

The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training (CPT code 97116) or self-care/home management training (CPT code 97535). Periodic revisits beyond the third month would require documentation to support medical necessity of this training.

Prosthetic checkout (CPT code 97762)

Prosthetic checkout is an end-service that identifies the examination of an orthotic/prosthetic device to insure a correct fit when using the orthotic or prosthetic during functional activities. An example of this is checking for skin integrity where the orthotic/prosthetic device may apply pressure. Any adjustments or repairs may be made to insure alignment and reinstruction may be given as well.

These assessments are reasonable and necessary when there is a modification or re-issue of a recently issued device or a reassessment of a newly issued device. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls.) Documentation in the medical record must clearly justify the medical necessity of the prosthetic check.

This code differs from 97760 which is intended to be used for orthotics fitting and training.

Physical medicine procedure (CPT code 97799)

For all claims submitted with this unlisted procedure code, a complete narrative description (detailing the type of physical medicine/rehabilitation service or procedure being performed) and the treatment plan supporting the medical necessity of the service must be submitted with the claim.

Coverage Limitations

Services that are palliative in nature are not considered necessary and reasonable and are not covered services. These services maintain function and generally do not involve complex physical medicine and rehabilitative procedures nor do they require clinician judgment and skill for safety and effectiveness.

If evaluation of the patient demonstrates that the patient does not have the potential to achieve significant improvement, in a reasonable and generally predictable period of time, with the proposed physical medicine and rehabilitative services, services would not be covered because they would not be considered reasonable and necessary.

Services that can be safely and effectively furnished by non-skilled personnel without the supervision of qualified professionals are not rehabilitative therapy services. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative, or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer be considered reasonable and necessary. Services that are not reasonable or necessary are not covered as per §1862(a)(1) of the Act.

Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction of function (e.g., temporary weakness which may follow a brief period of bed rest following abdominal surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities. Therapy furnished in such situations is not considered reasonable and necessary for the treatment of the individual's illness or injury and the services are not covered.

Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation) do not constitute physical medicine and rehabilitative services for Medicare purposes.

Reimbursement for an evaluation will be limited to once per injury/illness course. Many patients may complete their course of physical medicine and rehabilitative services without ever needing a re-evaluation service, while others may need one or more re-evaluations performed during their course of treatment because of a change in status or needs. Medicare will cover no more than two re-evaluations per patient per course of injury/illness; generally it is expected that this will occur no sooner than once per thirty (30) days.

The application of hot and cold packs is considered an integral part of a service or visit by CMS. Therefore, billing for the application of hot or cold packs (97010) will be denied. CPT code 97010 is a status B (bundled) code on the Medicare Fee Schedule Data Base (MFSDB). Separate payment is not allowed for this service.

Heat modalities (97024, 97035) used for the treatment of asthma, bronchitis and other pulmonary conditions are considered not reasonable and necessary and will be denied.

It is not medically necessary to have more than one form of hydrotherapy during a visit. Therefore, CPT codes 97022, 97036 or 97113 cannot be billed together.

As described in the Medicare National Coverage Determinations Manual, IOM Pub. 100-03, section 160.3, electrical nerve stimulation (97032, G0283) for the treatment of motor function disorders, such as multiple sclerosis, is not considered reasonable and necessary. Electrical stimulation is not considered reasonable or necessary for the treatment of strokes when it is determined that there is no potential for restoration of function. Electrical stimulation used for the treatment of facial nerve paralysis (e.g., Bell's Palsy), is considered investigational and therefore non-covered.

Gait training (97116) is not considered reasonable and necessary when the patient's walking ability is not expected to improve.

Work hardening (97545) and work hardening add-on (97546) services relate solely to specific work skills. They will be denied as not medically necessary for the diagnosis or treatment of illness or injury.

Due to the duplication of services represented by procedure code 97140 for manual manipulation, soft tissue mobilization, joint mobilization and the codes for osteopathic manipulation (98925-98929), separate payment will not be allowed if any of these codes are billed for the same patient on the same day.

Certifications and recertifications by doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law. Optometrists may order and certify only low vision services. Chiropractors may not certify or recertify plans of care for therapy services.

Additional Specific Limitation for Visual Rehabilitation Services

The provision of conventional refraction aids and the immediate instruction in their use are not covered, unless related to the treatment following cataract surgery.

Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.

Code 97010 is a status B (bundled) code on the Medicare Fee Schedule Data Base (MFSDB). Separate payment is not allowed for this service.

It is the provider's responsibility to select codes carried out to the highest level of specificity and selected from the ICD-9-CM code book appropriate to the year in which the service is rendered for the claim (s) submitted.

These ICD-9-CM codes apply to all CPT/HCPCS codes listed above EXCEPT 97026: