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1 MP Physical Therapy Medical Policy Section Therapy Issue 12/2013 Original Policy Date 12/2013 Last Review Status/Date Reviewed by consensus/12/2013 Return to Medical Policy Index Disclaimer Our medical policies are designed for informational purposes only and are not an authorization, or an explanation of benefits, or a contract. Receipt of benefits is subject to satisfaction of all terms and conditions of the coverage. Medical technology is constantly changing, and we reserve the right to review and update our policies periodically. Description Physical therapy (PT) is the treatment of disease or injury by the use of therapeutic exercise and other interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, a person s ability to go through the functional activities of daily living, and on alleviating pain. Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiological principles. Policy Physical therapy services are considered medically necessary when performed to meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention. Policy Guidelines Physical therapy services must meet all of the following criteria: meet the functional needs of a patient who suffers from physical impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention; achieve a specific diagnosis-related goal for a patient who has a reasonable expectation of achieving measurable improvement in a reasonable and predictable period of time; provide specific, effective, and reasonable treatment for the patient s diagnosis and physical condition; be delivered by a qualified provider of physical therapy services. A qualified provider is one who is licensed where required and performs within the scope of licensure; 42 Memorial Drive Suite 1 Pinehurst, N.C Phone (910) Fax (910)

2 require the judgment, knowledge, and skills of a qualified provider of physical therapy services due to the complexity and sophistication of the therapy and the physical condition of the patient. Benefit Application Plans may wish to review their contract language on physical therapy services to ensure that the contract language is consistent with the Plan s medical policy on PT. Many Plans have visit or dollar maximums for PT services, or these services may be provided as a separate contractual benefit. Qualified providers of PT services may include: M.D. (medical doctor); D.O. (doctor of osteopathy); physical therapist; chiropractor (in some jurisdictions, chiropractors must be licensed to perform PT services); podiatrist (limited by licensure requirements); occupational therapist (limited by certification and licensure). Charges may appear for the following services under physical therapy. These services should be adjudicated separately: acupuncture (see Policy ); acupuncture is considered investigational; gait analysis (see Policy ); gait analysis is considered investigational. Inpatient benefits are considered not medically necessary if the hospital admission is solely for the purpose of receiving physical therapy. Sessions A physical therapy session is defined as up to 1 hour of PT (treatment and/or evaluation) or up to 3 PT modalities provided on any given day. These sessions may include: therapeutic exercise programs, including coordination and resistive exercises, to increase strength and endurance; various modalities including, but not limited to, thermotherapy, cryotherapy, hydrotherapy, and electrical stimulation; massage, traction, or mobilization techniques; and patient and family education in home exercise programs. 42 Memorial Drive Suite 1 Pinehurst, N.C Phone (910) Fax (910)

3 Up to 10 physical therapy sessions per year may be covered without prior authorization. All subsequent treatment is subject to individual consideration. Prior authorization is recommended to facilitate claims processing based on a review of the written plan of care. Plan of Care The plan of care should include: specific statements of long- and short-term goals; measurable objectives; a reasonable estimate of when the goals will be reached; the specific modalities and exercises to be used in treatment; and the frequency and duration of treatment. The plan of care should be updated as the patient s condition changes and should be recertified by a physician at least every 30 days. Duplicate Therapy Duplicate therapy is considered not medically necessary. When patients receive both physical and occupational therapy, the therapies should provide different treatments and not duplicate the same treatment. They must also have separate treatment plans and goals (see Occupational Therapy, policy No ). Non-Skilled Services Certain types of treatment do not generally require the skills of a qualified provider of PT services and are therefore not medically necessary. Services may include: passive range of motion (ROM) treatment, which is not related to restoration of a specific loss of function; any of the following treatments when given alone or to a patient who presents no complications: hot packs; hydrocollator; infrared heat; whirlpool baths; paraffin baths; Hubbard tank; cold packs; ice packs; and contrast baths. Benefits should be denied for these services. Maintenance Program A maintenance program consists of activities that preserve the patient s present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Benefits for the maintenance program itself, are not covered. Rationale 42 Memorial Drive Suite 1 Pinehurst, N.C Phone (910) Fax (910)

4 A search of literature was completed through the MEDLINE database for the period of January 1980 through December The search strategy focused on references containing the following Medical Subject Headings: Physical Therapy (including review or meta-analysis or practical clinical trial or guidelines) as indexed in the Abridged Index Medicus Physical Therapy and Iontophoresis Rehabilitation (massage or effleurage or pétrissage or tapotement) See also: Occupational Therapy, medical policy No Research was limited to English-language journals on humans. Codes Number Description CPT 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, , 97033, 97034, 97035, 97036, , 97112, 97113, 97116, 97124, Physical medicine and rehabilitation modalities, supervised, code range. Physical medicine and rehabilitation modalities, constant attendance, code range. Therapeutic procedures code range. ICD-9 Procedure Physical therapy code range ICD-9 Diagnosis Code applicable disease, trauma, congenital anomalies, or prior therapeutic treatment HCPCS Q0086 Physical therapy evaluation/treatment, per visit Q0103 Physical therapy evaluation code range Type of Service Medical Inpatient Outpatient Place of Service Physician s Office Physical Therapist s Office Home Index 42 Memorial Drive Suite 1 Pinehurst, N.C Phone (910) Fax (910)

5 Cryotherapy Exercise Programs, Therapeutic Hydrotherapy Physical Therapy Therapy, Physical Thermotherapy 42 Memorial Drive Suite 1 Pinehurst, N.C Phone (910) Fax (910)