Coverage Policies

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Physical and occupational therapy services (rehabilitative services to restore a loss of function) are covered only if the services are ordered (prescribed) by a physician or chiropractor and provided by a licensed physical therapist, licensed physical therapy assistant supervised by a licensed physical therapist, licensed occupational therapist, or licensed occupational therapy assistant supervised by a licensed occupational therapist.  If services are provided by a physical therapy assistant or occupational therapy assistant, they must be billed by the supervising physical therapist or occupational therapist.

2)    Physical and occupational therapy rehabilitative services (to restore a loss of function) require a plan of care signed by the therapist and physician.

3)    Most plans limit the number of physical therapy visits that will be covered in a calendar year.  See your plan documents for limits.

4)    Physical and occupational therapy services for habilitative purposes (for congenital disabilities or developmental delays) are only covered by certain plans—see your coverage documents and BI 398  

5)    Work conditioning, work hardening programs and group therapies are not covered.

1)    Physical and occupational therapy services are covered only when provided by a provider licensed to provide those particular services.

2)    Physical and occupational therapy services require that a plan of care be in place.  The plan of care must meet these specific guidelines:

a)    Established prior to treatment

b)    Dated when dictated and/or written

c)    Includes the type, amount, frequency and duration of the therapy services to be provided

d)    Indicates the diagnosis and anticipated goals

e)    Signed by the ordering physician and by the physician or therapist who developed the plan of care.

3)    Initial evaluation is allowed once per course of treatment:

a)    97161 – 97163 — Physical Therapy Evaluation

b)    97165 – 97167 — Occupational Therapy Evaluation

4)    Re–evaluation is allowed every twelve visits, or if there is a significant change in the patient’s status, such as a significant new symptom.  Reevaluation other than at the 12 visit interval should be supported with clinical documentation of a significant change in status.

a)    97164 — Physical Therapy Re–evaluation

b)    97168 — Occupational Therapy Re–evaluation

5)    97010 – Application of hot/cold packs is considered to be a part of the provision of other therapy services and will not be separately reimbursed.

6)    S8948 – Application of low level laser is considered experimental and investigational and is not covered.

7)    Continuation of therapy past twelve visits requires reevaluation by the treating physician with renewal of the therapy prescription. Such continuation may be subject to review for medical necessity. 

8)    97032 – 97535 – Timed physical therapy codes require documentation of the actual time spent by the therapist in each procedure, as well as the total actual time spent by the therapist with that individual patient. 

a)    Time with an individual patient need not be undivided, but it is expected that the only time billed will be time the therapist spent in one-on-one contact with that patient. 

b)    QualChoice follows CMS guidelines for documentation of therapist time:

i)     8 – 22 minutes equals one 15 minute unit

ii)    23 – 37 minutes equals two units…and so on.

iii)   The number of units billed for the entire visit may not exceed that which would be calculated for the total time spent with the patient. In other words, 60 minutes of total therapist time is four units, even if that therapist spent 12 minutes performing each of 5 different activities.

9)    97545 – 97546 – Work conditioning and work hardening are not covered.

10) 97039, 97139 (unlisted modalities/procedures) and 97150 (group therapy) are not covered.

Codes Used In This BI:

·         Continued therapy will not be approved for patients who are not showing objective functional improvement.

·         Unlisted therapies/procedures and group therapies are not covered.

Physical or occupational therapy treatment consists of a prescribed program to relieve symptoms, improve function and prevent further disability for individuals disabled by chronic or acute disease or injury. Treatment may include various forms of heat and cold, electrical stimulation, therapeutic exercises, ambulation training and training in functional activities.  Progressive therapeutic exercise is the most effective form of therapy for most treatable causes of disability.

Medically necessary therapy services must be restorative or for the purpose of designing and teaching maintenance program for the patient to carry out at home. The services must also relate to a written treatment plan and be of a level of complexity that requires the judgment, knowledge and skills of a physical therapist, occupational therapist, medical doctor, doctor of osteopathy, or doctor of chiropractic to perform and/or supervise the services. The amount, frequency and duration of the therapy services must be reasonable, the services must be considered appropriate and needed for the treatment of the disabling condition, and services must not be palliative or in nature.

Below is a description and medical necessity criteria for different treatment modalities and therapeutic procedures.

1. Hot/Cold Packs (97010) – Hot packs increase blood flow, relieve pain and increase movement; cold packs decrease blood flow to an area to reduce pain and swelling immediately after an injury. Because application of hot or cold packs does not require special training or supervision, use of these modalities is considered included in other therapy services and will not be separately reimbursed.
2. Traction (97012) – Manual or mechanical pull on extremities or spine to relieve spasm and pain – supervised. This modality, when provided by physicians or physical therapists, is typically used in conjunction with therapeutic procedures, not as an isolated treatment. For cervical radiculopathy, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home.   
3. Electrical Stimulation (97014, 97032) – Application of an electrical current to the skin via surface electrodes; this can either be supervised (not requiring one-to-one contact by the provider) or constant attendance (requiring one-to-one contact by the provider).  Electrical stimulation can be used either as a pain relief modality (TENS) or to stimulate muscle contraction. 
4. Vasopneumatic Device (97016) – Pressure application by special equipment to reduce swelling - supervised. See BI227.
5. Paraffin Bath (97018) – Also known as hot wax treatment, this involves supervised application of heat (via hot wax) to an extremity to relieve pain and facilitate movement. This is considered medically necessary for pain relief in chronic joint problems of the wrists, hands or feet. One or two visits are usually sufficient to educate the individual in home use and to evaluate effectiveness.
6. Diathermy (e.g., microwave) (97024) – Deep, dry heat with high frequency current or microwave to relieve pain and increase movement - supervised. The objective of diathermy is to cause vasodilatation and relieve pain from muscle spasm. Diathermy using deep dry heat with high frequency achieves a greater rise in deep tissue temperature than dose microwave. Considered medically necessary as a heat modality for painful musculoskeletal conditions.
7. Iontophoresis (97033) – Electric current used to transfer certain medications (usually steroids) transcutaneously into body tissues. May be considered medically necessary in patients with sub-acute or chronic inflammation of a joint or tendon, when used in conjunction with a therapeutic program including stretching and exercise.
8. Contrast Baths (97034) – Blood vessel stimulation with alternate hot and cold baths - constant attendance is needed. This modality may be considered medically necessary to treat extremities affected by reflex sympathetic dystrophy, acute edema resulting from trauma, or synovitis/tenosynovitis. It is generally used as an adjunct to a therapeutic procedure, preferably therapeutic exercise.
9. Ultrasounds (97035) – Deep heat by high frequency sound waves to relieve pain, improve healing - constant attendance. This modality is considered medically necessary to treat arthritis, inflammation of per articular structures, and sub-acute inflammation after injury.
10. Therapeutic Exercises (97110) – Instructing a person in exercises and directly supervising the exercises. Purpose is to restore and/or maintain muscle strength and flexibility including range of motion, stretching and postural drainage. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively (e.g., treadmill, isokinetic exercise lumbar stabilization, stretching, strengthening). Therapeutic exercise is considered medically necessary for loss or restriction of joint motion, strength, functional capacity or mobility which has resulted from disease or injury.  Therapeutic exercise is the core therapeutic activity for restoration of function.  Note: Exercising done subsequently by the member without a physician or therapist present and supervising would not be covered, nor would a period of unsupervised ‘warm-up’ exercise.
11.  Neuromuscular Re–education (97112) – This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception to a person who has had muscle paralysis or other significant neurological injury. Goal is to develop conscious control of individual muscles and awareness of position of extremities. The procedure may be considered medically 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/hyper tonicity) that may result from disease or injury such as severe trauma to the nervous system, cerebral vascular accident, or systemic neurological disease.  This treatment is only appropriate for patients whose function is expected to improve with treatment.
12. Aquatic Therapy/Hydrotherapy/Hubbard Tank (97036, 97113) – Hubbard tank involves a full-body immersion tank for treating severely burned, debilitated and/or neurologically impaired individuals. Pool therapy (aquatic therapy, hydrotherapy) is provided individually, in a pool, to severely debilitated or neurologically impaired individuals. (The term is not intended to refer to relatively normal individuals who exercise, swim laps or relax in a hot tub or Jacuzzi.) Develops and/or maintains muscle strength including range of motion by eliminating forces of gravity through total body immersion (except for head) - requires constant attention. It is not considered medically necessary to provide more than one type of hydrotherapy on the same day (e.g., whirlpool, Hubbard tank, hydrotherapy).
13. Gait Training (97116) – Teaching individuals with severe neurological or musculoskeletal disorders to ambulate in the face of their handicap or to ambulate with an assistive device. Gait training is considered medically necessary for training individuals whose walking abilities have been impaired by neurological, muscular or skeletal abnormalities or trauma. Gait training is not considered medically necessary when the individual`s walking ability is not expected to improve. Provider supervision of ongoing walk-strengthening exercise for feeble or unstable patients is not considered medically necessary. Gait training is not considered medically necessary for relatively normal individuals with minor or transient abnormalities of gait who do not require an assistive device; these minor or transient gait abnormalities may be remedied by simple instructions to the individual.
14. Massage Therapy (97124) – Massage involves manual techniques that include applying fixed or movable pressure, holding and/or causing movement of or to the body, using primarily the hands. These techniques affect the musculoskeletal, circulatory-lymphatic, nervous, and other systems of the body with the intent of improving a person`s well-being or health. The most widely used forms of massage therapy include Swedish massage, deep-tissue massage, sports massage, neuromuscular massage, and manual lymph drainage. Massage therapy is not a covered benefit under most plans.
15. Manual Therapy Techniques (97140) – Soft tissue mobilization through manipulation. Skilled manual techniques (active and/or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are myofascial release, manual traction, manual lymphatic drainage, and facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened connective tissue. This procedure is considered medically necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk.
16. Therapeutic activities (97530) – This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, pushing, pulling, stooping, catching and overhead activities) to restore 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 professional skills of a provider and are designed to address a specific functional need of the member. This intervention may be appropriate after a patient has completed exercises focused on strengthening and range of motion but need to be progressed to more function-based activities. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.  These are considered medically necessary only for restorative purposes, and are not covered for purposes of improving recreational or work performance. 
17. Cognitive skills development (97532) – This procedure is considered medically necessary for persons with acquired cognitive defects resulting from head trauma, or acute neurologic events including cerebrovascular accidents. It is not appropriate for persons with chronic progressive brain conditions with any potential for restoration. Occupational/speech therapists or clinical psychologists with specific training in these skills are typically the providers. This procedure should be aimed at improving or restoring specific functions which were impaired by an identified illness or injury. The goals of therapy, expected outcomes and expected duration of therapy should be specified.
18. Activities of Daily Living (ADL) Training (97535) – Training of severely impaired individuals in essential activities of daily living, including bathing; feeding; preparing meals; toileting; walking; making bed; and transferring from bed to chair, wheelchair or walker. This procedure is considered medically necessary to enable the member to perform essential activities of daily living related to the patient`s health and hygiene, within or outside the home, with minimal or no assistance from others. This procedure is considered medically necessary only when it requires the professional skills of a provider, is designed to address specific needs of the member, and must be part of an active treatment plan directed at a specific outcome. The member must have the capacity to learn from instructions.
19. Work hardening/conditioning (97545 – 97546) – Services designed to assist an injured worker return to his/her job of injury through exercises that emulate or substantially reproduce work activities.  These services are properly considered part of the workers’ compensation system and are not covered under QualChoice plans.

The medical necessity of neuromuscular reeducation, therapeutic exercises, and/or therapeutic activities, performed on the same day, must be documented in the medical record.  The record should reflect the requirement for each of these different techniques, the specific ways in which each technique was utilized, the amount of time spend in each, and the separate goal for each.

Only one heat modality would be considered medically necessary during the same treatment session. An exception to this is ultrasound (a deep heat), which may be considered medically necessary with one superficial heat modality but is not considered medically necessary with other deep heat modalities.

Physical and occupational therapy should be provided in accordance with an ongoing, written plan of care developed by the physician or by the therapist in collaboration with the physician. The purpose of the written plan of care is to assist in determining medical necessity and should include the following:

1. The diagnosis along with the date of onset or exacerbation of the disorder/diagnosis;
2. A reasonable estimate of when the goals will be reached;
3. Long-term and short-term goals that are specific, quantitative and objective;
4. Physical therapy evaluation;
5. The frequency and duration of treatment;
6. The specific treatment techniques and/or exercises to be used in treatment;
7. A signature of the patient’s attending physician and physical therapist.