National Imaging Associates, Inc. Clinical guidelines THERAPY AND REHABILITATION SERVICES (PT, OT) Original Date: October 2015 Page 1 of 34

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1 Natinal Imaging Assciates, Inc. Clinical guidelines THERAPY AND REHABILITATION SERVICES (PT, OT) Original Date: Octber 2015 Page 1 f 34 FOR CMS (MEDICARE) MEMBERS ONLY CPT4 Cdes: Please refer t pages Last Effective Date: January 2017 LCD ID Number: L35036 J H = AR, CO, LA, MS, NM, OK, TX J L = PA, NJ, MD, DE, DC Respnsible Department: Clinical Operatins Last Revised Date: May 2017 Implementatin Date: May 2017 FOR CMS (MEDICARE) MEMBERS ONLY Cverage Indicatins, Limitatins, and/r Medical Necessity Ntice: It is nt apprpriate t bill Medicare fr services that are nt cvered (as described by this entire LCD) as if they are cvered. When billing fr nn-cvered services, use the apprpriate mdifier. Cmpliance with the prvisins in this plicy may be mnitred and addressed thrugh pst payment data analysis and subsequent medical review audits. This LCD prvides guidelines fr many physical medicine and rehabilitatin services. Hwever, this LCD des nt address all services, including BUT NOT LIMITED TO: Speech-language pathlgy services fr cmmunicatin disrders (see LCD L35070) Services related t wund care (see applicable LCD) Services related t swallwing prblems r dysphagia, including VitalStim therapy (see LCD L34891) Services primarily addressed by CMS Natinal Cverage Determinatins (NCDs), including BUT NOT LIMITED TO: Cardiac Rehabilitatin Prgrams (NCD 20.10), Manipulatin (NCD 150.1), Fluidized Therapy Dry Heat fr Certain Musculskeletal Disrders (NCD 150.8), Treatment f Psriasis (NCD 250.1), NCD fr Neurmuscular Electrical Stimulatr (NMES) (NCD ). DEFINITIONS (Nte fr a cmplete list f definitins that are applicable t this LCD, refer t IOM, Pub , Medicare Benefit Plicy Manual, Chapter 15, Sectin 220, A.) ACTIVE PARTICIPATION f the clinician in treatment means that the clinician persnally furnishes in its entirety at least ne billable service n at least ne day f treatment. 1 Therapy_Rehab Ser (PT_OT) - CMS

2 ASSESSMENT is separate frm evaluatin and is included in services r prcedures (it is nt separately reimbursable). INTERVAL f certified treatment (certificatin interval) cnsists f 90 calendar days r less, based n an individual s needs. A physician/nn-physician practitiner (NPP) may certify a plan f care fr an interval length that is less than 90 days. There may be mre than ne certificatin interval in an episde f care. The certificatin interval is nt the same as a Prgress Reprt perid. MAINTENANCE PROGRAM (MP) means a prgram established by a therapist that cnsists f activities r mechanisms that will assist a patient in maximizing r maintaining the prgress he r she has made during therapy r t prevent r slw further deteriratin due t a disease r illness. THERAPY SERVICES are thse skilled services furnished accrding t the standards and cnditins in CMS manuals, (e.g., in IOM, Pub , Medicare Benefit Plicy Manual, Chapter 15, Sectin 220, A. and in IOM, Pub , Medicare Claims Prcessing Manual, Chapter 5), within their scpe f practice by qualified prfessinals r qualified persnnel. TREATMENT DAY means a single calendar day n which treatment, evaluatin r reevaluatin is prvided. There culd be multiple visits, treatment sessins/encunters n a treatment day. COMPLEXITIES refer t cmplicating factrs that may influence treatment, e.g., they may influence the type, frequency r duratin f treatment, may be represented by diagnses (see IOM, Pub , Medicare Benefit Plicy Manual, Chapter 15, Sectin 220); by patient factrs such as age, severity, acuity, multiple cnditins, c-mrbidities, and mtivatin; r by the patient s scial circumstances, such as the supprt f a significant ther r the availability f transprtatin t therapy. GENERAL PHYSICAL MEDICINE & REHABILITATION (PM&R) GUIDELINES This LCD applies t the therapy services cded with the 97XXX series f CPT cdes and canalith repsitining therapy. Per CMS definitins, therapy services include these services with a few exceptins. Please refer t the dcuments fund at fr the cmplete listing f CPT cdes that are always cnsidered therapy services and thse that are smetimes cnsidered therapy services fr cverage, requirement fr plan f care, and cding purpses. Physical medicine and rehabilitative services are designed t imprve, restre, r cmpensate fr lss f physical functining fllwing disease, injury r lss f a bdy part. Clinicians use the clinical histry, systems review, physical examinatin, and a variety f evaluatins t determine the impairments, functinal limitatins, and disabilities f the individual patient. Impairments, functinal limitatins, and disabilities thus identified are 2 Therapy_Rehab Ser (PT_OT) - CMS

3 then addressed by the design and implementatin f a plan f care tailred t the specific needs f the individual patient. Specific interventins are selected, applied, r mdified based n the examinatin data, the evaluatin, the diagnsis and prgnsis, and the anticipated gals and expected utcmes. The patient must have a ptential fr restratin r imprvement f lst functins, and must require the services f a skilled therapist. Rehabilitatin services are nt cvered if the patient is unable t cperate in the treatment prgram r if clear gals are nt definable. Mst rehabilitatin is shrt-term and intensive, and maintenance therapy services required t maintain a level f functining is nt cvered. Fr example, a persn wuld generally be eligible fr, and may be prvided, rehabilitatin services under selfcare/hme management training, (i.e., activities f daily living, cmpensatry training, meal preparatin, safety prcedures, and instructin in the use f adaptive equipment). PM&R services in patients hmes, qualified prfessinals ffices, Skilled Nursing Facilities (SNFs), utpatient hspital clinics, Outpatient Rehabilitatin Facilities (ORFs) and Cmprehensive Outpatient Rehabilitatin Facilities (CORFs) are cvered when reasnable and medically necessary fr the treatment f the patient s cnditin (signs and symptms). Fr payment by Medicare, direct supervisin is required fr private practice licensed PTA services alng with all ther criteria fr licensed physical therapy assistants (PTA) services, unless state practice requirements are mre stringent, in which case state r lcal requirements must be fllwed. General supervisin is required fr all ther settings fr licensed PTA services. Fr example, in clinics, rehabilitatin agencies, and public health agencies, 42 CFR indicates that when a PTA prvides services, either n r ff the rganizatin s premises, thse services are supervised by a qualified physical therapist wh makes an nsite supervisry visit at least nce every 30 days r mre frequently if required by state r lcal laws r regulatin. The services f a PTA shall nt be billed as services incident t a physician/nn-physician prvider (NPP) s service, because they d nt meet the qualificatins f a therapist. Interventin with PM&R mdalities and prcedures is indicated when: an assessment by a physician, NPP r therapist supprts utilizatin f the interventin, there is dcumentatin f bjective physical and functinal limitatins (signs and symptms), and the written plan f care incrprates thse treatment elements that require services f a skilled therapist fr a reasnable and generally predictable perid f time. Medicare cvers therapy services persnally perfrmed nly by ne f the fllwing: Licensed therapy prfessinals: licensed physical therapists and ccupatinal therapists. 3 Therapy_Rehab Ser (PT_OT) - CMS

4 Licensed PTA with apprpriate supervisin by a licensed physical therapist. Licensed ccupatinal therapy assistants (OTA) with apprpriate supervisin by a licensed ccupatinal therapist. Medical Dctrs (MDs) and Dctrs f Ostepathy (DOs). Dctrs f Optmetry (ODs) and Pdiatric Medicine (DPMs) when perfrming services within their licenses scpe f practice and their training and cmpetency. Qualified NPPs, including Advanced Nurse Practitiners (ANPs), Physician Assistants (PAs) r Clinical Nurse Specialists (CNSs) when perfrming services within their licenses scpe f practice and their training and cmpetency (ANP, PA, CNS). Qualified persnnel when apprpriately supervised by a physician (MD, DO, OD, DPM) r qualified NPP, and when all cnditins f billing services incident t a physician have been met. Qualified persnnel prviding physical therapy (PT) r ccupatinal therapy (OT) services incident t the services f a physician/npp must have met the educatinal and degree requirements f a licensed therapy prfessinal (PT, OT) frm an accredited PT/OT curriculum, but are nt required t be licensed. Please nte that unless these therapy services are perfrmed by a qualified persn, the services are nt cvered and must nt be reprted fr Medicare payment. Cvered Therapy services under Medicare must: Qualify as skilled therapy services; Be cnsidered under accepted standards f medical practice t be a specific and effective treatment fr the patient's cnditin; Be f such a level f cmplexity and sphisticatin r the cnditin f the patient shall be such that the services required can be safely and effectively perfrmed nly by a qualified therapist, r in the case f physical therapy and ccupatinal therapy by r under the supervisin f a qualified therapist; and The amunt, frequency, and duratin f the services must be reasnable under accepted standards f practice. Therefre, therapy services are cvered when they are rendered: under written treatment plan develped by the individual's physician, nn-physician practitiners, ptmetrist, r therapist; t address specific therapeutic gals fr which mdalities and prcedures are planned ut specifically in terms f type, frequency and duratin; and the patient's functinal limitatins are dcumented in terms that are bjective and measurable. Other specific requirements include the fllwing: Medicare cvers therapy services that require the skill f a trained and licensed practitiner t perfrm r supervise. Medicare des nt cver therapy services that d nt require the skill f a trained and licensed practitiner t perfrm even when ne f the persns in the list abve perfrms them. 4 Therapy_Rehab Ser (PT_OT) - CMS

5 If canalith repsitining is perfrmed by therapy persnnel under a therapy plan f care, Medicare expects a physical therapist t perfrm the service. A written plan f care, cnsisting f diagnses (lng-term treatment gals and type, amunt, duratin and frequency f therapy services), must be established by the physician, NPP, r therapist prviding the services befre the services are begun. The plan is established when it is develped (e.g., written r dictated). The plan must be peridically reviewed by the physician r NPP. A therapist may nt significantly alter a plan f care established r certified by the physician r NPP withut their dcumented written r verbal apprval. The plan must be certified and recertified peridically (see "Dcumentatin Requirement" fr details) by the physician r NPP. New r significantly mdified plan(s) f care must be certified within 30 calendar days after the initial treatment under that plan, unless delayed certificatin criteria are met. If certificatin is btained verbally, it must be fllwed by a signature within 14 days t be timely. Recertificatin must be btained within the duratin f the initial plan f care r within 90 calendar days f the initial treatment under that plan, whichever is less. Services prvided cncurrently by a physician, physical therapist and ccupatinal therapist may be cvered if separate and distinct gals are dcumented in the treatment plan(s). The amunt f treatment refers t the number f times in a day the type f treatment will be prvided. Where amunt is nt specified, ne treatment sessin a day is assumed. The frequency refers t the number f times in a week the type f treatment is prvided. Where frequency is nt specific, ne treatment is assumed. If a scheduled hliday ccurs n a treatment day that is part f the plan, it is apprpriate t mit that treatment day unless the clinician wh is respnsible fr writing prgress reprts determines that a brief, temprary pause in the delivery f therapy services wuld adversely affect the patient's cnditin. The duratin is the number f weeks, r the number f treatment sessins, fr this plan f care. If the episde f care is anticipated t extend beynd the 90 calendar day limit fr certificatin f a plan, it is desirable, althugh nt required, that the clinician als estimate the duratin f the entire episde f care in this setting. The frequency r duratin f the treatment may nt be used alne t determine medical necessity, but they shuld be cnsidered with ther factrs such as cnditin, prgress, and treatment type t prvide the mst effective and efficient means t achieve the patients' gals. Fr all PM&R mdalities and therapeutic prcedures n a given day, it is usually nt medically necessary t have mre than ne treatment sessin per discipline. Treatment times per sessin vary based upn the patient s medical needs and prgress tward established gals. Treatment times per sessin typically will nt exceed minutes. Additinal time is smetimes required fr mre cmplex r slw-t-respnd patients. 5 Therapy_Rehab Ser (PT_OT) - CMS

6 Hwever, dcumentatin f the exceptinal circumstances must be maintained in the patient s medical recrd and be made available upn request. General Guidelines fr Therapeutic Prcedures CPT Cdes: 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97545, 97546: Therapeutic prcedures are prcedures that attempt t reduce impairment and imprve functin thrugh the applicatin f clinical skills r services. Per CPT guidelines, use f these prcedures requires that the practitiner have direct (ne-n-ne) patient cntact. (Please see the grup therapy sectin belw fr further clarificatin.) A service is nt cnsidered a skilled therapy service merely because it is furnished by a therapist r by a therapist/therapy assistant under the direct r general supervisin, as applicable, f a therapist. If the service can be self-administered r safely and effectively furnished by an unskilled persn, withut the direct r general supervisin f a therapist, the service cannt be regarded as a skilled therapy service even when a therapist actually furnishes the service. Similarly, the unavailability f a cmpetent persn t prvide a nn-skilled service, ntwithstanding the imprtance f the service t the patient, des nt make it a skilled service when a therapist furnishes the service. Cdes fr therapeutic exercises, neurmuscular re-educatin, aquatic therapy/exercises, and therapeutic activities describe several different types f therapeutic interventins. The expected gals dcumented in the treatment plan, affected by the use f each f these prcedures, will help define whether these prcedures are reasnable and medically necessary. Therefre, since any ne r a cmbinatin f mre than ne, f therapeutic exercises, neurmuscular re-educatin, aquatic therapy/exercises and therapeutic activities may be used in a treatment plan, the dcumentatin must supprt the use f each cde as it relates t specific therapeutic gal(s). Dcumentatin supprting the medical necessity fr cntinued treatment must be made available t Medicare upn request. The fllwing clinical guidelines pertain t the specific listed therapeutic prcedures. Per Change Request 2083 In accrdance with established cnditins, all rehabilitatin services t beneficiaries with a primary visin impairment diagnsis must be prvided pursuant t a written treatment plan established by a Medicare Physician and implemented by apprved Medicare qualified prfessinals (physical therapists r ccupatinal therapists) r as "incident t" physician services. Sme f the fllwing rehabilitatin prgrams/services fr beneficiaries with visin impairment may include Medicare cvered therapeutic services. Mbility. 6 Therapy_Rehab Ser (PT_OT) - CMS

7 Activities f daily living. Other medically necessary services, including lw-visin services. REHABILITATIVE THERAPY The crnerstnes f rehabilitative therapy are mbilizatin, educatin and therapeutic exercise. The gal f rehabilitative medicine is discernible, functinal prgress tward the restratin r maximizatin f impaired neurmuscular and musculskeletal functin. T that end, the dynamic cmpnents f therapy, mbilizatin, and patient educatin shuld predminate. Passive mdalities shuld be used in the "warm-up" phase f the patient encunter as preparatin fr r as an adjunct t therapeutic prcedures, and in the "cldwn" phase fr reductin f pain, swelling and ther pst-treatment syndrmes. Thugh passive mdalities may predminate in the earlier phases f rehabilitatin where the patient's ability t participate in therapeutic exercise is restricted, Medicare expects these mdalities t never be the sle r predminant cnstituent f a therapy plan f care. Further, Medicare expects the patient's recrd t clearly reflect medical necessity fr passive mdalities, especially thse that exceed 25 percent f the cumulative service hurs f rehabilitative therapy prvided fr any beneficiary under a plan f care. In mre refractry cases, the practitiner will supprt the need fr cntinued care with dcumentatin that clearly utlines the factrs that require cntinued skilled care. The cntractr recgnizes variability in strength, recvery time and the ability t be educated, and allws fr a recertificatin fr additinal therapy, as lng as adequate medical dcumentatin by the supervising physician r therapist is recrded in the medical recrd and the patient cntinues t require the services f a skilled caregiver. In all cases, whether the duratin and intensity f rehabilitative services recmmended r rendered are limited r extensive fr passive r active services, Medicare expects the patient's medical recrd t clearly demnstrate medical reasnableness and necessity fr all therapy services. When a service is prvided beynd a patient's Medicare benefit and it is determined t be nt medically necessary, it is denied by Medicare as a benefit categry denial. Therapeutic exercise and activities are essential fr rehabilitatin. The use f mdalities as stand-alne treatment is nt indicated as a sle apprach t rehabilitatin. Therefre, an verall curse f rehabilitative treatment is expected t cnsist predminantly f therapeutic prcedures (such as therapeutic exercises, neurmuscular re-educatin, gait training therapy, r therapeutic activities), with adjunctive use f mdalities. Althugh passive mdalities may play a larger rle in the early stages f rehabilitatin and in treating exacerbatins it is expected that mdalities will cmprise a small prtin f the ttal therapy service time invlved during the curse f rehabilitative therapy. Further, it is expected that the recrd will demnstrate bth the patient's clinical prgress and cncmitant apprpriate increasingly active therapeutic treatment. MAINTENANCE THERAPY 7 Therapy_Rehab Ser (PT_OT) - CMS

8 A maintenance prgram cnsists f activities that preserve the patient's present level f functin r prevent regressin f that functin. During the last visits fr rehabilitative treatment, it may be reasnable and medically necessary fr the clinician t develp a maintenance prgram, and instruct the patient, family member(s) r caregiver(s) in carrying ut the maintenance prgram. It is nt medically necessary fr a qualified prfessinal t perfrm r supervise maintenance prgrams that d nt require the prfessinal skills f a qualified prfessinal. These situatins include: Services related t activities fr the general gd and welfare f patients (e.g., general exercises t prmte verall fitness and flexibility). Repetitive exercises t maintain gait r maintain strength and endurance, and assisted walking such as that prvided in supprt fr feeble r unstable patients. Range f mtin and passive exercises that are nt related t restratin f a specific lss f functin, but are useful in maintaining range f mtin (fr example: in paralyzed extremities). Maintenance therapies after the patient has achieved therapeutic gals r fr patients wh exhibit n ptential fr prgress and shuld becme patient r caregiver-directed. Cverage fr maintenance therapy services is prvided when the skills f a therapist are necessary t maintain, prevent, r slw further deteriratin f the patient s functinal status, and the services cannt be safely and effectively carried ut by the beneficiary persnally, r with the assistance f nn-therapists, including unskilled caregivers. Dcumentatin, either with bjective evidence r a clinically supprtable statement f expectatin, must be available that supprts the necessity f the skilled services prvided. Further, patients with lng term, chrnic cnditins may ccasinally need skilled input t update r revise their hme maintenance prgram; and t assess the need fr new, r changes t existing, assistive r adaptive equipment. Peridic evaluatins f the patient s cnditin and respnse t treatment may be cvered when medically necessary if the judgment and skills f a qualified prfessinal are required. Examples include: Design f a maintenance regimen required t delay r minimize muscular and functinal deteriratin in patients suffering frm a chrnic disease. Instructing the patient, family member(s) r caregiver(s) in carrying ut the maintenance prgram. Infrequent re-evaluatins required t assess the patient's cnditin and adjust the prgram. If a maintenance prgram is nt established until after the therapy prgram has been cmpleted (and the skills f a therapist are nt necessary), develpment f a maintenance prgram is nt cnsidered reasnable and necessary fr the patient s cnditin. General Mdality Guidelines 8 Therapy_Rehab Ser (PT_OT) - CMS

9 (CPT Cdes: 97012, 97018, 97022, 97024, 97028, 97032, 97033, 97034, 97035, 97036, 97039) Mdality cdes fr mechanical tractin vaspneumatic device, paraffin bath therapy, whirlpl therapy, diathermy, and ultravilet therapy, require supervisin by the qualified prfessinal. Mdality cdes fr electrical stimulatin, cntrast bath therapy, ultrasund therapy, hydrtherapy, and physical therapy treatment unlisted require direct (ne-n-ne) cntact with the patient by the qualified prfessinal. Generally, adjunctive use f services billed with mechanical tractin and paraffin bath therapy is cverable nly if they enhance the therapeutic prcedures. Dcumentatin supprting the medical necessity and clinical justificatin fr the cntinued use f these services must be made available t Medicare upn request. Generally, nly ne heating mdality per day f therapy is reasnable and necessary. Medicare wuld nt expect t see multiple heating mdalities billed rutinely n the same day. Exceptins culd include musculskeletal pathlgy/injuries in which bth superficial and deep structures are impaired. Dcumentatin cntaining clinical justificatin supprting the medical necessity fr multiple heating mdalities such as paraffin bath therapy, diathermy, and ultrasund therapy n the same day is essential. Generally, nly ne hydrtherapy mdality is cverable per day when the sle purpse is t relieve muscle spasm, inflammatin r edema. Dcumentatin must be available supprting the use f multiple mdalities as cntributing t the patient s prgress and restratin f functin. Because sme f the mdalities are cnsidered cmpnents f ther mdalities and prcedures, they are nt separately reimbursed. Please refer t the Crrect Cding Initiative. Specific Mdality Guidelines The fllwing clinical guidelines pertain t the specific mdalities listed. Electrical Stimulatin fr the Treatment f Wunds (CPT/HCPCS Cdes G0281-G0282) Medicare prvides limited cverage f electrical stimulatin fr the treatment f wunds. Please refer t the Natinal Cverage Determinatin (NCD) Electrical Stimulatin (ES) and Electrmagnetic Therapy fr the Treatment f Wunds fr cmplete cverage details. Electrical Stimulatin fr Indicatins Other Than Wund Care (CPT/HCPCS Cde G0283) Electrical stimulatin fr indicatins ther than wund care is cnsidered medically necessary when perfrmed as an integral part f the therapy plan f care. CPT/HCPCS G0283 This mdality includes the fllwing types f electrical stimulatin: Transcutaneus Electrical Nerve Stimulatin (TENS). 9 Therapy_Rehab Ser (PT_OT) - CMS

10 Micramperage E-Stimulatin (MENS). Percutaneus Electrical Nerve Stimulatin (PENS). Electrgalvanic stimulatin (high vltage pulsed current). Functinal electrical stimulatin. Interferential current/medium current. These types f electrical stimulatin may be necessary during the initial phase f treatment, but there must be an expectatin f imprvement in functin. Electrical stimulatin must be utilized with apprpriate therapeutic prcedures (e.g., CPT Cde 97110) t effect cntinued imprvement. Electrical stimulatin is typically used in cnjunctin with therapeutic exercises. It is expected this mdality will be used in a clearly adjunctive rle and nt as a majr cmpnent f the therapeutic encunter. When electrical stimulatin is used fr muscle strengthening r retraining, the nerve supply t the muscle must be intact. It is nt medically necessary fr cmpletely denervated mtr nerve disrders in which there is n ptential fr recvery r restratin f functin. Medicare cvers pelvic flr electrical stimulatin with a nn-implantable stimulatr fr the treatment f stress r urge urinary incntinence in cgnitively intact patients wh have failed a dcumented trial f pelvic muscle exercise (PME) training. See CMS Publicatin , Medicare Natinal Cverage Determinatins (NCD) Manual, sectin fr infrmatin n Nn-Implantable Pelvic Flr Electrical Stimulatin. This mdality des nt require direct (n-n-ne) patient cntact by the prvider. Please refer t LCD L36434, Micrvascular Therapy (MVT), fr infrmatin regarding these services. CPT cde (mechanical tractin) This mdality, when prvided by physicians r independent physical therapists, is typically used in cnjunctin with therapeutic prcedures, nt as an islated treatment; hwever, it may be used in weaning an acute patient t a self-administered hme prgram. Equipment and tables utilizing rller systems are nt cnsidered true mechanical tractin. Services using this type f equipment are nn-cvered. When mdality cdes fr mechanical tractin and paraffin bath therapy are used alne (absent therapeutic prcedures and nt as a precursr t active treatment) and slely t prmte healing, relieve muscle spasm, reduce inflammatin and edema, r as analgesia, a limited number f visits (e.g., 1 2 visits) may be medically necessary t determine the effectiveness f treatment and fr patient educatin. It is usually nt medically reasnable and necessary t cntinue mdality-nly treatment by the qualified prfessinal. 10 Therapy_Rehab Ser (PT_OT) - CMS

11 Dcumentatin shuld supprt the medical necessity f cntinued tractin treatment in the clinic fr greater than 12 visits. Fr cervical cnditins, treatment beynd ne mnth can usually be accmplished by self-administered mechanical tractin in the hme. The time devted t patient educatin related t the use f hme tractin shuld be billed under mechanical tractin. Only 1 unit f mechanical tractin is generally cvered per date f service. CPT cde (vaspneumatic device therapy) The use f vaspneumatic devices may be cnsidered medically necessary fr the applicatin f pressure t an extremity fr the purpse f reducing edema. Specific indicatins fr the use f vaspneumatic devices include: reductin f edema after acute injury; lymphedema f an extremity; r educatin n the use f a lymphedema pump fr hme use. Nte: Further treatment f lymphedema by a prvider after the educatinal visits is generally nt medically necessary. Educatin fr the hme use f a lymphedema pump is smetimes prvided by the lymphedema pump supplier. If the supplier des nt prvide this educatin, limited therapy prfessinal visits fr such purpses are allwable. Educatin n the use f a lymphedema pump fr hme use can typically be cmpleted in n mre than three (3) visits. Medicare des nt expect t be rutinely billed fr repeated lymphedema treatments. The use f vaspneumatic devices wuld nt be cvered as a temprary treatment while awaiting receipt f rdered cmpressin stckings. Medicare expects that dcumentatin in the physician s medical recrd must supprt the necessity f repeated services. CPT cde (paraffin bath therapy) Als knwn as ht wax treatment, paraffin bath therapy is primarily used fr pain relief in chrnic jint prblems f the wrists, hands r feet. Paraffin bath treatments typically d nt require the unique skills f a therapist. Hwever, the skills, knwledge and judgment f a therapist might be required in the prvisin f such treatment r baths in a cmplicated case. Only in cases with cmplicated cnditins will paraffin be cvered, and then cverage is generally limited t educating the patient/caregiver in hme use. Paraffin is cntraindicated fr pen wunds r areas with dcumented desensitizatin. Once a trial f mnitred paraffin treatment has been dne in the clinic ver 1-2 visits and the patient has had a favrable respnse, the patient can usually be taught t use a paraffin unit in 1-2 visits. Cnsequently, it is inapprpriate fr a patient t cntinue paraffin treatment in the clinic setting. 11 Therapy_Rehab Ser (PT_OT) - CMS

12 Only 1 unit f paraffin bath therapy is generally cvered per date f service. CPT cde (whirlpl therapy) and CPT cde (hydrtherapy) These mdalities invlve the use f agitated water t relieve muscle spasms, imprve circulatin r prmte the healing f wunds (e.g., ulcers, exfliative skin cnditins). Whirlpl bath treatments typically d nt require the unique skills f a therapist. Physician r therapist supervisin f the whirlpl mdality must be medically necessary fr the fllwing indicatins: The patient s cnditin is cmplicated by: Circulatry deficiency. Areas f desensitizatin. Impaired mbility r limitatins in the psitining f the patient. Cncerns abut safety, if left unsupervised. If greater than 8 visits are needed fr whirlpl treatments that require the skills f a therapist, the dcumentatin shuld supprt the medical necessity f the cntinued treatment. Dcumentatin supprting the medical necessity fr additinal sessins must be made available t Medicare upn request. It is nt medically necessary t have mre than ne frm f hydrtherapy during a treatment sessin. It wuld nt be cnsidered reasnable and necessary fr a patient t have whirlpl services n the same date f service as a debridement service (CPT cdes ) perfrmed n the same bdy part. Fluidtherapy (Billable as CPT cde 97022) Fluidtherapy is a superficial dry heat mdality cnsisting f a whirlpl f finely divided slid particles suspended in a heated air stream, the mixture having the prperties f a liquid. Medicare allws the use f fluidized therapy dry heat as an acceptable alternative t ther heat therapy mdalities in the treatment f acute r sub-acute traumatic r nntraumatic musculskeletal disrders f the extremities. See CMS IOM, Publicatin , Medicare Natinal Cverage Determinatins (NCD) Manual, Chapter 1, Sectin Diathermy (CPT cde 97024) Shrt wave diathermy is an effective mdality fr heating skeletal muscle. Because heating is accmplished withut physical cntact between the mdality and the skin, it can be used even if skin is abraded, as lng as there is n significant edema. The use f diathermy is cnsidered medically necessary fr the delivery f heat t deep tissues such as skeletal muscle and jints fr the reductin f pain, jint stiffness, and muscle spasms. Specific indicatins fr the use f diathermy include: 12 Therapy_Rehab Ser (PT_OT) - CMS

13 the patient has stearthritis, rheumatid arthritis, r traumatic arthritis; the patient has sustained a strain r sprain; the patient has acute r chrnic bursitis; the patient has sustained a traumatic injury t muscle, ligament, r tendn resulting in functinal lss; the patient has a jint dislcatin r subluxatin; the patient requires treatment fr a pst-surgical functinal lss; the patient has an adhesive capsulitis; r the patient has a jint cntracture. Diathermy is nt cnsidered medically necessary fr the treatment f asthma, brnchitis, r any ther pulmnary cnditin. High energy pulsed wave diathermy machines (diathermy/diapulse) have been determined t prduce the same therapeutic benefit as standard diathermy. Therefre, any reimbursement fr diathermy will be made at the same level as standard diathermy. Ultravilet Therapy (CPT cde 97028) Phtns in the ultravilet (UV) spectrum are mre energetic than thse in the visible r infrared regins. Their interactin with tissue and bacteria can prduce nn-thermal phtchemical reactins, the effects f which prvide the ratinale fr ultravilet treatment. Ultravilet light is highly bactericidal t mtile bacteria, and it increases vascularizatin at the margins f the wunds. The applicatin f ultravilet therapy is cnsidered medically necessary fr the patient requiring the applicatin f a drying heat when prescribed by the attending physician. The specific indicatins fr this therapy are: A patient having an pen wund. Minimal erythema dsage must be dcumented and made available t Medicare upn request. Severe psriasis limiting range f mtin. Only 1 unit f ultravilet therapy is cvered per date f service. Supprtive Dcumentatin Requirements (required at least every 10 visits) fr Ultravilet Therapy: Area(s) being treated Objective clinical findings/measurements t supprt the need fr ultravilet therapy Minimal erythema dsage CPT cde (electrical stimulatin) - See prcedure cde G0283 fr pelvic flr electrical stimulatrs. 13 Therapy_Rehab Ser (PT_OT) - CMS

14 Nn-wund care electrical stimulatin treatment prvided in therapy is cmmnly billed as prcedure cde G0283 as it is ften prvided in a supervised manner (after skilled applicatin by the qualified prfessinal/auxiliary persnnel) withut cnstant, direct cntact required thrughut the treatment. Electrical stimulatin mdality requires direct (ne-n-ne) manual patient cntact by the qualified prfessinal/auxiliary persnnel. Dcumentatin shuld clearly describe the type f electrical stimulatin prvided, as well as the medical necessity f the cnstant cntact t justify billing electrical stimulatin. Devices delivering high vltage stimulatin may require ne-n-ne patient cntact. Types f electrical stimulatin that may require cnstant cntact include the fllwing examples: Direct mtr pint stimulatin delivered via a prbe Instructing a patient in the use f a hme TENS unit Once a trial f TENS has been dne in the clinic ver 1-2 visits and the patient has had a favrable respnse, the patient can usually be taught t use a TENS unit fr pain cntrl in 1-2 visits. Cnsequently, it is inapprpriate fr a patient t cntinue treatment fr pain with a TENS unit in the clinic setting. Use fr Walking in Patients with Spinal Crd Injury (SCI). The type f neurmuscular electrical stimulatin (NMES) that is used t enhance the ability t walk fr spinal crd injury (SCI) patients is cmmnly referred t as functinal electrical stimulatin (FES). See CMS IOM, Publicatin , Medicare Natinal Cverage Determinatins (NCD) Manual, sectin fr infrmatin n cverage fr this use f NMES. Nte: Cverage fr this indicatin is limited t thse patients where the nerve supply t the muscle is intact, including brain, spinal crd and peripheral nerves, and ther nnneurlgical reasns fr disuse are causing the atrphy (e.g., pst-casting r splinting f a limb, and cntracture due t sft tissue scarring). Sme patients can be trained in the use f a hme muscle stimulatr fr retraining weak muscles. Only 1-2 visits shuld be necessary t cmplete the training. Once training is cmpleted, this prcedure shuld nt be billed as a treatment mdality in a facility. Supprtive Dcumentatin Requirements (required at least every 10 visits) fr Electrical Stimulatin: Type f electrical stimulatin used (d nt limit the descriptin t manual r attended ) Area(s) being treated If used fr muscle weakness, bjective rating f strength and functinal deficits If used fr pain include pain rating, lcatin f pain, effect f pain n functin CPT cde (Intphresis - t ne r mre areas) 14 Therapy_Rehab Ser (PT_OT) - CMS

15 Intphresis is the intrductin int the tissues, by means f an electric current, f the ins f a chsen medicatin. This mdality is used t reduce pain and edema caused by a lcal inflammatry prcess in sft tissue, e.g., tendnitis, bursitis. The evidence frm published, peer-reviewed literature is insufficient t cnclude that the intphretic delivery f nn-steridal anti-inflammatry drugs (NSAIDs) r crticsterids is superir t placeb when used fr the treatment f musculskeletal disrders. Therefre, intphresis will nt be cvered fr these indicatins. Intphresis will be allwed fr treatment f intractable, disabling primary fcal hyperhidrsis (See Grup 1 Diagnses Cdes) that has nt been respnsive t recgnized standard therapy. In thse allwable situatins, the prcedure is reprtable fr the time putting it n r remving r fr prviding instructin fr use at hme. Gd hygiene measures, extra-strength antiperspirants (fr axillary hyperhidrsis), and tpical aluminum chlride shuld initially be tried. CPT cde (cntrast bath therapy) Cntrast baths are a frm f therapeutic heat and cld applied t distal extremities in an alternating pattern. The effectiveness f cntrast baths is thught t be due t reflex hyperemia prduced by the alternating expsure t heat and cld. Ht and cld baths rdinarily d nt require the skills f a therapist. Hwever, the skills, knwledge and judgment f a therapist might be required in the prvisin f such treatments in a particular case, e.g., where the patient s cnditin is cmplicated by circulatry deficiency, areas f desensitizatin, pen wunds, fracture r ther cmplicatin. Dcumentatin must indicate the presence f these cmplicating factrs fr reimbursement f this cde. If there are n cmplicating factrs requiring the skills f a therapist, this mdality is nn-cvered. Cntrast bath therapy is nt cvered when the services prvided are ht and cld packs. It is cnsidered reasnable and necessary fr cntrast bath therapy t be used in cnjunctin with therapeutic prcedures and nt as an islated treatment. Cntrast bath therapy is a cnstant attendance cde requiring direct, ne-n-ne patient cntact by the prvider. Only the actual time f the prvider s direct cntact with the patient is t be billed. N mre than 2 visits will generally be cvered t educate the patient r caregiver in hme use, and t evaluate effectiveness. Dcumentatin must supprt the medical necessity f cntinued use f cntrast bath therapy fr greater than 2 visits. Supprtive Dcumentatin Requirements (required at least every 10 visits) fr Cntrast Bath Therapy: 15 Therapy_Rehab Ser (PT_OT) - CMS

16 Ratinale requiring the unique skills f a therapist t apply, including the cmplicating factrs Area(s) being treated Subjective findings t include pain ratings, pain lcatin, effect n functin CPT cde (ultrasund therapy) Therapeutic ultrasund is a deep heating mdality that prduces a sund wave f 0.8 t 3.0 MHz. In the human bdy ultrasund has several prnunced effects n bilgic tissues. It is attenuated by certain tissues and reflected by bne. Thus, tissues lying immediately next t bne may receive as much as 30% greater dsage f ultrasund than tissue nt adjacent t bne. Because f the increased extensibility ultrasund prduces in tissues f high cllagen cntent, cmbined with the clse prximity f jint capsules, tendns, and ligaments t crtical bne where tissue may receive a mre intense irradiatin, ultrasund is an ideal mdality fr increasing mbility in thse tissues. It is cnsidered reasnable and necessary that ultrasund may be pulsed r cntinuus width; and fr it t be used in cnjunctin with therapeutic prcedures, nt as an islated treatment. Specific indicatins fr the use f ultrasund applicatin include but are nt limited t: limited jint mtin that requires an increase in extensibility symptmatic sft tissue calcificatin neurmas Phnphresis (the use f ultrasund t enhance the delivery f tpically applied drugs) will be reimbursed as ultrasund therapy. Separate payment will nt be made fr the cntact medium r drugs. If n bjective r subjective imprvement is nted after 6 treatments, a change in treatment plan (alternative strategies) shuld be implemented r dcumentatin shuld supprt the need fr cntinued use f ultrasund. Dcumentatin must clearly supprt the need fr ultrasund mre than 12 visits. Supprtive Dcumentatin Requirements (required at least every 10 visits) fr Ultrasund Therapy: Area(s) being treated Frequency and intensity f ultrasund Objective clinical findings such as measurements f range f mtin and functinal limitatins t supprt the need fr ultrasund Subjective findings t include pain ratings, pain lcatin, effect n functin CPT cde (Hubbard Tank - t ne r mre areas) 16 Therapy_Rehab Ser (PT_OT) - CMS

17 This mdality invlves the patient s immersin in a tank f agitated water in rder t relieve muscle spasm, imprve circulatin, r cleanse wunds, ulcers, r exfliative skin cnditins. One-n-ne supervisin f the patient by qualified prfessinal/auxiliary persnnel is required. Hubbard tank treatments mre than 12 visits require clear dcumentatin supprting the medical necessity f cntinued use f this mdality and the cntinued necessity fr the services f a skilled therapist. It is nt medically necessary t have mre than ne frm f hydrtherapy during a visit (whirlpl therapy and Hubbard Tank therapy). Supprtive Dcumentatin Requirements fr CPT cde 97036: Ratinale requiring the unique skills f a therapist t apply, including the cmplicating factrs and area(s) being treated. Specific Guidelines fr Therapeutic Prcedures The fllwing clinical guidelines pertain t the specific listed therapeutic prcedures. CPT cde (therapeutic exercises) Therapeutic exercise is designed t develp strength and endurance, range f mtin, and flexibility and may include: active, active-assisted r passive (e.g., treadmill, iskinetic exercise, lumbar stabilizatin, stretching, strengthening) exercises. The exercise may be reasnable and medically necessary fr a lss r restrictin f jint mtin, strength, functinal capacity r mbility that has resulted frm a specific disease r injury. It is cnsidered reasnable and necessary if an exercise is taught t a patient and perfrmed by a skilled therapist fr the purpse f restring functinal strength, range f mtin, endurance training, and flexibility. Dcumentatin must shw bjective lss f jint mtin, strength r mbility (e.g., degrees f mtin, strength grades, levels f assistance). This therapeutic prcedure is measured in 15-minute units with therapy sessins frequently cnsisting f several units. Many therapeutic exercises may require the unique skills f a therapist t evaluate the patient s abilities, design the prgram, and instruct the patient r caregiver in safe cmpletin f the special technique. Hwever, after the teaching has been successfully cmpleted, repetitin f the exercise, and mnitring fr the cmpletin f the task, in the absence f additinal skilled care, is nn-cvered. CPT cde (neurmuscular re-educatin) This therapeutic prcedure is prvided t imprve balance, crdinatin, kinesthetic sense, 17 Therapy_Rehab Ser (PT_OT) - CMS

18 psture, and prpriceptin (e.g., prpriceptive neurmuscular facilitatin, Feldenkrais, Bbath, BAP s bards and desensitizatin techniques). The prcedure may be reasnable and medically necessary fr impairments that affect the bdy s neurmuscular system (e.g., pr static r dynamic sitting/standing balance, lss f grss and fine mtr crdinatin, hyp/hypertnicity). Fr example, a gym ball exercise used fr the purpse f imprving balance shuld be cnsidered as neurmuscular reeducatin. CPT cde (aquatic therapy) This prcedure uses the therapeutic prperties f water (e.g.: buyancy, resistance). The prcedure may be reasnable and medically necessary fr a lss r restrictin f jint mtin, strength, mbility r functin that has resulted frm a specific disease r injury. Dcumentatin must shw bjective lss f jint mtin, strength r mbility (e.g.: degrees f mtin, strength grades, level f assistance). D nt use this cde fr situatins where n exercise is being perfrmed in the water envirnment (e.g.: debridement f ulcers). When aquatic therapy is prvided in a cmmunity pl, the prvider must rent r lease at least a prtin f the pl fr the exclusive use f the patients. NOTE: Fr requirements n furnishing therapy service in a pl, please refer t IOM, Pub , Medicare Benefit Plicy Manual, Chapter 15, Sectin 220C fr a cmplete discussin n renting/leasing pl space, use f the rented/leased space, and dcumentatin required t supprt these requirements. In additin, aquatic therapy may be cnsidered medically necessary when: the patient cannt perfrm land-based exercises effectively t treat their cnditin withut first underging the aquatic therapy, r aquatic therapy facilitates prgressin t land-based exercise r increased functin. Dcumentatin must be available in the recrd t supprt medical necessity. It is nt medically necessary t emply hydrtherapy and aquatic therapy during the same treatment sessin. Nte: Hydrtherapy refers t whirlpl therapy and Hubbard Tank therapy. CPT cde (gait training therapy) This prcedure may be medically necessary fr training patients whse walking abilities have been impaired by neurlgical, muscular, r skeletal abnrmalities r trauma. This prcedure is nt reasnable and necessary if the patient des nt require skilled care. 18 Therapy_Rehab Ser (PT_OT) - CMS

19 Repetitive walk-strengthening exercises fr feeble r unstable patients r t increase endurance d nt require qualified prfessinal supervisin and will be denied as nt reasnable and necessary. Generally, it wuld nt be cnsidered reasnable and necessary t perfrm gait training therapy in cnjunctin with rthtic management and training. An exceptin t this wuld be if rthtic management and training was perfrmed n an upper extremity in cnjunctin with gait training. CPT cde (massage therapy) This prcedure may be medically necessary as adjunctive treatment t anther therapeutic prcedure n the same day, which is designed t restre muscle functin, reduce edema, imprve jint mtin r fr relief f muscle spasm. CPT cde (manual therapy) Manual therapy such as mbilizatin, manipulatin, manual tractin and manual lymphatic drainage. Myfascial Release/Sft Tissue Mbilizatin This prcedure may be medically necessary fr the treatment f restricted mtin f sft tissues invlving the extremities, neck r trunk. Skilled manual techniques (active r passive) are applied t effect changes in the sft tissues, articular structures, neural r vascular systems. Examples include: Facilitatin f fluid exchange Restratin f mvement in acutely edematus; muscles Stretching f shrtened cnnective tissue This prcedure may be medically necessary as an adjunct t ther therapeutic prcedures such as therapeutic exercises neurmuscular re-educatin, r therapeutic activities. Jint Mbilizatin This prcedure may be medically necessary as an adjunct t therapeutic exercises when lss f articular mtin and flexibility impedes the therapeutic prcedure. Dcumentatin supprting the medical necessity fr cntinued treatment must be made available t Medicare upn request. Manipulatin This prcedure may be medically necessary as an adjunct t ther therapeutic prcedures such as therapeutic exercises, neurmuscular re-educatin, r therapeutic activities. 19 Therapy_Rehab Ser (PT_OT) - CMS

20 Manual Lymphatic Drainage/Cmplex Decngestive Therapy (MLD/CDT) MLD/CDT is indicated fr bth primary and secndary lymphedema. Cmmn causes include surgical remval f lymph ndes, fibrsis secndary t radiatin, and traumatic injury t the lymphatic system. Bth primary and secndary lymphedemas are chrnic and prgressive cnditins which can be brught under lng-term cntrl with effective management. By maintaining cntrl f the lymphedema, patients can: restre a nrmal, r near-nrmal, shape reduce the ptential fr cmplicatins (e.g., cellulitis, lymphangitis, defrmity, injury, fibrsis, lymphangisarcma (rare), etc.) reduce functinal deficits t resume activities f daily living MLD/CDT cnsists f skin care, manual lymph drainage, cmpressin wrapping, and therapeutic exercises. Cverage f MLD/CDT wuld nly be allwed if all f the fllwing cnditins have been met: there is a physician-dcumented diagnsis f lymphedema (primary r secndary) the patient has dcumented signs r symptms f lymphedema the patient r patient caregiver has the ability t understand and cmply with the cntinuatin f the treatment regimen at hme The gal f treatment is t reduce lymphedema f an extremity by ruting the fluid t functinal pathways, preventing backflw as the new rutes becme established, and t use the mst apprpriate methds t maintain such reductin f the extremity after therapy is cmplete. This therapy invlves intensive treatment t reduce the vlume by a cmbinatin f manual decngestive therapy and serial cmpressin bandaging, fllwed by an exercise prgram. Ultimately the plan must be t transfer the respnsibility f care frm the therapist t management by the patient, patient s family, r patient s caregiver. In mderate-severe lymphedema, daily visits may be required fr the first week Educatin shuld be prvided t the patient r caregiver n the crrect applicatin f the cmpressin bandage The therapeutic exercise cmpnent fr MLD/CDT is cvered under therapeutic exercises service Dcumentatin must clearly supprt the need fr cntinued manual therapy treatment beynd visits. When the patient r caregiver has been instructed in the perfrmance f specific techniques, the perfrmance f these same techniques shuld nt be cntinued in the clinic setting and cunted as minutes f skilled therapy Massage is nt cvered n the same visit as a MLD/CDT service. CPT cde (grup therapeutic prcedures) 20 Therapy_Rehab Ser (PT_OT) - CMS

21 In the case f grup therapy, Medicare expects that skilled, medically necessary services will be prvided as apprpriate t each patient s plan f care. Therefre, grup therapy sessins (tw r mre patients) shuld be f sufficient length t address the needs f each f the patients in the grup. Althugh grup therapy services are included with the therapeutic prcedures that require ne-n-ne patient cntact, these services invlve cnstant attendance f the qualified health care prfessinal, but by definitin d nt require ne-n-ne patient cntact by the same health care prfessinal. Dcumentatin must identify the specific treatment technique(s) used in the grup, hw the treatment technique will restre functin, the frequency and duratin f the particular grup setting, and the treatment gal in the individualized (patient-specific) plan. The number f persns in the grup must als be dcumented. These recrds must be made available t Medicare upn request. CPT cde (therapeutic activities) This prcedure invlves using functinal activities (e.g., bending, lifting, carrying, reaching, catching and verhead activities) t imprve functinal perfrmance. The activities are usually directed at a lss r restrictin f mbility, strength, balance r crdinatin. They require the prfessinal skills f a qualified prfessinal and are designed t address a specific functinal need f the patient. These dynamic activities must be part f an active treatment plan and directed at a specific utcme. CPT cde (cgnitive skills develpment) This activity fcuses n cgnitive skills develpment t imprve attentin, memry and prblem-slving, with direct ne-n-ne patient cntact by the qualified prfessinal, each 15 minutes. Cgnitive skill training shuld be aimed twards imprving r restring specific functins which were impaired by an identified illness r injury, and expected utcmes shuld be reasnably attainable by the patient as specified by the plan f care. Therefre, cgnitive skills training fr cnditins withut ptential fr imprvement r restratin, such as chrnic prgressive brain cnditins, wuld nt be apprpriate. Evidence-based reviews indicate that cgnitive rehabilitatin (and specifically memry rehabilitatin) is nt recmmended fr patients with severe cgnitive dysfunctin. Cgnitive skills are an imprtant cmpnent f many tasks, and the techniques used t imprve cgnitive functining are integral t the brader impairment being addressed. Cgnitive therapy techniques are mst ften cvered as cmpnents f ther therapeutic prcedures, and typically wuld nt be separately reprted. Activities billed as cgnitive skills develpment include nly thse that require the skills f a therapist and must be prvided with direct (ne-n-ne) cntact between the patient and 21 Therapy_Rehab Ser (PT_OT) - CMS