Physical and Occupational Therapy # 01059 What is it? CPT Codes 97001 97004, 97010 97028, 97032, 97034 97039, 97110 97140, 97530 Experimental or Non-Covered Codes S8940, S9090, E0830, E0941, 97005, 97006, 97033, 97150, 97545, 97546, 97799 Physical therapy (PT) and Occupational therapy (OT) are considered medically necessary when performed with the expectation of restoring the patient s functional ability that has been lost or reduced by injury, surgery or illness. In addition, the treatment must be prescribed by a physician. Open access or self referred therapy is not considered medically appropriate. Therapy must also be provided in accordance with an ongoing, written treatment plan. Therapy treatment plans must include all of the following: a) patient s diagnosis; and, b) degree of severity of the problem; and, c) impairment characteristics (such as unable to ambulate without assistance); and, d) physical findings (x-ray, range of motion or other studies); and, e) specific long and short term goals; and, f) reasonable time when goals will be reached (number of visits for specified number of weeks); and, g) frequency of treatment (number of times per week); and, h) the modalities/procedures to be used in treatment; and, i) equipment and/or techniques utilized. A typical session usually consists of up to 1 hour of rehabilitation therapy. Therefore, precertification is approved based on 2 units (30 minutes) of therapeutic exercise and up to 3 modalities. Modalities or time in excess of such standards may be reviewed and approved or disapproved based upon individual case. Notes: PT and OT are determined in accordance with the patient s benefit plan. Many plans include a maximum allowable benefit for duration of treatment or number of visits. Most benefit plans exclude coverage for services, treatment, education testing or training related to learning disabilities or developmental delays and/or for which therapy is not restorative in nature (patient never had capacity to start). Under plans with this exclusion, therapy would not be covered when the primary or only diagnosis for a member is mental retardation or a learning disability such as a perceptual handicap, autism, brain damage not caused by accidental injury, minimal brain dysfunction, dyslexia, or developmental delay. Please refer to the applicable benefit plan to determine benefit availability and the terms and conditions of coverage. 1
Criteria Initial precertification requires fax of: a) physician script; and, b) initial evaluation (upon completion). After review, an authorization number will be provided for the evaluation as well as continuing visits when medically appropriate. The treatment plan should be updated as the patient s condition changes. Continuation of therapy beyond original authorization requires fax of: a) ongoing progress notes; and, b) an updated script. Additional review will be made to extend the number of visits when medically appropriate. Documentation must show: 1) reasonable improvement; and, 2) continued improvement is possible within a reasonable time period. PT or OT is considered not medically necessary for any of the following: 1) asymptomatic persons; or, 2) persons without an identifiable clinical condition; or, 3) once therapeutic benefit has been achieved; or, 4) when a home exercise program could be used for further gains; or, 5) persons whose condition is neither regressing nor improving; or, 6) persons whose goals are "return to sports"; or, 7) when services are provided to prevent or slow deterioration in function or prevent recurrences; or, 8) services performed repetitively to maintain a level of function (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.) 9) when services are to improve or maintain general physical condition. The following treatments or programs are specifically excluded under most benefit plans and are considered to be non-medical, educational or training in nature and not medically necessary: work hardening programs (97545, 97546); or, back school; or, vocational rehab programs and any program with the primary goal of returning an individual to work; or, group physical therapy (97150); or, services for purpose of returning to or enhancing athletic performance or for recreational abilities. 2
PT / OT Billing Guidelines Physical and Occupational therapy evaluation and re-evaluations 97001 97004 - The following are inherent and not separately reimbursable on the same date as evaluation or re-evaluation: 99211 99215 (not all inclusive listing) - Evaluation and management (E&M) services. Note: Modifier 25 may be reported with medical care (e.g. visits, consults) to identify it as significant and separately identifiable from the other service(s) provided on the same day. When modifier 25 is reported, the patient s records must clearly document that separately identifiable medical care was rendered. 95831 95834 Muscle testing 95851 95852 Range of motion measurements and report 96150 96154 Health and behavioral assessment and intervention 97750 Physical performance test 97755 - Assistive technology assessment 97762 Checkout for orthotic or prosthetic use 97802 97804 or G0270 G0271 Medical nutrition therapy 99605 99606 Medication therapy management services Athletic training evaluation and re-evaluation 97005 97006 is not considered medically necessary. Supervised Modalities (do not require direct one-on-one patient contact). 97010 97028 Supervised Modalities are not time-based codes and can only be reported once during a patient encounter regardless of the amount of time spent supervising the modality or the number of body areas treated. 97010 Hot/Cold Packs 97012 Mechanical Traction 97014 Electrical Stimulation (unattended) 97016 Vasopneumatic Compression intermittent compression therapy used to reduce edema and lymphedema of the extremities. This treatment is warranted for the following conditions: - Edema of extremities (729.81, 757.0, 782.3) - Hematoma of the leg (921.00 924.10, 924.4, 924.5) - Lymphedema of the arm or leg (457.0 457.1) - Venous insufficiency or venous stasis disorder (459.81) 3
97018 Paraffin Bath 97022 Whirlpool Conditions other than those listed above or those which indicate that an infection is present are considered not medically necessary. Documentation must be available to support the application of a compression device and should include the type, amount and location of edema as well as the circumferential measurements of the treated extremity before and after treatment. Devices which provide both vasopneumatic compression and cold or hot therapy simultaneously are to be reported with only code 97016 (not 97010 in addition). 97024 Diathermy (microwave) deep, dry heat with high frequency current 97026 Infrared Light Therapy uses dry heat with a special lamp to increase circulation to an area under supervision. Note: Infrared light therapy is not considered medically necessary when used for treatment of diabetic and/or non-diabetic peripheral sensory neuropathy and wounds and/or ulcers of the skin and/or subcutaneous tissues. IMPORTANT: Cold laser therapy also known as low level laser therapy (such as MicroLight 830, Axiom BioLaser LLLT Series 3, Acculaser Pro4, Thor DDII IR Lamp System or 830 CL3 Laser System, Luminex LL Laser System) and monochromatic nearinfrared photo energy (Anodyne Therapy System) are considered experimental and investigational. 97028 Ultraviolet Therapy Constant Attendance Modalities (require direct one-on-one patient contact by the provider and time based codes.) 97032 97039-97032 Electrical stimulation (manual) 97033 Iontophoresis is considered experimental and investigational and unproven as a PT or OT modality. See Policy 01045 for use of iontophoresis for Hyperhidrosis. 97034 Contrast Baths 97035 Ultrasound Therapy 97036 Hubbard Tank 97039 Unlisted Modality Certain PT modalities and therapy are considered duplicative in nature and are inappropriate to perform or bill for services during the same session such as: 1) Whirlpool, Aquatic therapy and Hubbard tank (97022, 97113 and 97036) 2) Infrared and Ultraviolet (97026 and 97028) 4
3) Microwave and infrared (97024 and 97026) 4) Paraffin Bath and Fluidized Therapy (Fluidotherapy ) high intensity heat modality consisting of a dry whirlpool of finely divided solid particles suspended in a heated air stream having properties of liquid) (97018 97036) Therapeutic Procedures and Activities 97110 97530 97110 Therapeutic Exercises 97112 Neuromuscular Re-education standard treatment is 12 18 visits within a 4 6 week period. 97113 Aquatic Therapy provider must have direct (one to one) patient contact. Supervising multiple patients in a pool at one time and billing for each of them per 15 minutes of therapy is not acceptable. If a provider cannot substantiate increased resistance experienced as the patient exercises in water, the session is considered as endurance or conditioning rather than progressive resistance exercises to strengthen and is not medically necessary. Charges for aquatic exercise programs or separate charges for use of a pool are not covered. Payment of 97113 includes 97022 (whirlpool) and/or 97036 (Hubbard tank). 97116 Gait Training generally accepted indications for gait training include foot drop from stoke, herniated disc, ankle, knee and/or hip replacement or traumatic amputations of the toe. 97124 - Massage Therapy (some plans specifically exclude coverage for massage therapy). If not excluded, it is considered medically necessary as part of a comprehensive PT or OT plan. Massage therapy provided in the absence of other therapeutic modalities is considered not medically necessary. Massage therapy is not considered medically necessary for prolonged periods and is limited to the initial or acute phase of an injury or illness (initial 2 week period). 97139 Unlisted Therapeutic Procedure 97140 Manual Therapy Techniques 97150 Group Therapy is considered not medically necessary. 97530 Dynamic therapeutic activities The following services are considered experimental and investigational or not medically necessary: Augmented Soft Tissue Mobilization experimental and investigational noninvasive mobilization techniques to treat chronic musculoskeletal disorders that 5
result from scarring and fibrosis using hand-held tools made from bone, stone or metal and a lubricant to scrape and mobilize scar tissue. There is insufficient evidence to support the effectiveness of this technique. Dry Hydro Massage not medically necessary (97799) patient lies back on surface of a hydrotherapy table with a mattress filled with heated water. A pump propels water toward patient through hydro jets. Electomagnetic Stimulation experimental and investigational (97799) a magnetic field that penetrates the body creating nerve impulses that relax muscle spasms but effectiveness has not bee established. Equestrian / Hippotherapy experimental and investigational (S8940) therapeutic horseback riding (equine facilitated therapy or horse therapy) is passive use of physical movements of the horse in treatment but there is insufficient data to support effectiveness for any indication including individuals with cerebral palsy or other motor dysfunction such as arthritis, multiple sclerosis, head injury, stroke and spinal cord injury. Hands Free Ultrasound experimental and investigational (97799) lower intensity pulsed treatment with stationary sound head allows for a longer treatment time without therapist involvement but there is lack of evidence supporting it is as effective as traditional ultrasound. Horizontal Therapy experimental and investigational (97799) a form of bioelectrical stimulation with electric current moving horizontally through tissue rather than vertically. There are no long term studies as to the efficacy of this modality. Interactive Metronome Program experimental and investigational a program designed for processing speed, focus and coordination using headphones promoted as treatment for children with ADHD and patients with balance disorders, cerebrovascular accident, limb amputation, multiple sclerosis, Parkinson s disease and traumatic brain injury. However, there is insufficient evidence to support the effectiveness. Quantitative Muscle Testing (Isokinetic) and treatment devices experimental and investigational such as MedX, Isostation B-200, Cybex, Kin-Com and Biodex. Spinal Unloading Devices patient operated experimental and investigational (E0830, E0941, E1399) such as LTX 3000 and Orthotrac Pneumatic Vest. Vertebral Axial Decompression therapy and devices experimental and investigational (S9090) - such as VAX-D, DRX, DRX2000, DRX3000, DRX5000, DRX9000, DRS, Accu-SPINA System, IDD Therapy - Intervertebral Differential Dynamic Therapy, Tru Tac 401, Lordex Power Traction device, Spinerx LDM. Notice Policies are designed to provide medical guidelines that are applicable for the majority of individuals with a particular disease, illness, or condition. In addition, policies are designed to supplement the medical necessity terms as defined in the member's Policy or Benefit Plan. Therefore, policies alone can not override specific Policy or Benefit plan language regarding coverage, limitations and exclusions. In the event of conflict, the Policy or Benefit Plan shall govern. Any policies included herein do not constitute medical advice or the practice of medicine. Rather, they are intended only to establish general guidelines. Application of a policy to determine medical necessity in an individual instance is not intended, implied or construed to take priority over the professional judgment of a treating provider. In all situations, the treating provider must use professional judgment to provide the care believed to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions. Sentinel retains the right to review and update policies at its sole discretion. Policies are proprietary information of Sentinel. Any sale, copying or dissemination is prohibited; however, limited copying is permitted for individual use. 6