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.