ARBenefits Approval: Effective Date: 01/01/2014 Revision Date: Administered by: Medical Policy Title: Physical and Occupational Therapy Services Document: ARB0476 Public Statement: 1) Physical and occupational therapy must be preauthorized. 2) Physical and occupational therapy services are covered only if the services are ordered (prescribed) by a physician or chiropractor and provided by a physician or chiropractor or 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. 3) Work conditioning and work hardening programs are not covered. Medical Policy Statement: 1) Physical and occupational therapy services require preauthorization, and are covered only when provided by a provider licensed to provide those particular services. 2) Initial evaluation is allowed once per course of treatment a) 97001 physical therapy evaluation b) 97003 occupational therapy evaluation 3) Reevaluation 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) 97002 physical therapy reevaluation b) 97004 occupational therapy reevaluation 4) Application of hot or cold packs, 97010, is considered to be a part of the provision of other therapy services and will not be separately reimbursed. 5) Neuromuscular reeducation, 97112, is considered medically necessary for the following indications: a) For a patient who has had a muscle paralysis and is undergoing recovery or regeneration, b) Cerebrovascular accident impairing balance or proprioception Page 1 of 8
c) Nervous system trauma d) Other significant neurologic deficits 6) Timed physical therapy codes (97032-97535) 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-to-one contact with that patient. b) ARBenefits follows CMS guidelines for documentation of therapist time: i) 8-22 minutes equals one 15 minute unit ii) 23-37 minutes equals two units iii) And so on. iv) 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. 7) Work conditioning and work hardening (97545 and 97546) are not covered. Limits: 1) The use of neuromuscular re-education, 97112, for musculoskeletal injuries or back pain is considered not medically necessary. 2) Continued therapy will not be approved for patients who are not showing objective functional improvement. Codes Used in This Policy: 97001 Pt evaluation 97002 Pt re-evaluation 97003 Ot evaluation 97004 Ot re-evaluation 97010 Hot or cold packs therapy 97012 Mechanical traction therapy 97014 Electric stimulation therapy 97016 Vasopneumatic device therapy 97018 Paraffin bath therapy 97022 Whirlpool therapy 97024 Diathermy eg microwave 97026 Infrared therapy 97028 Ultraviolet therapy 97032 Electrical stimulation 97033 Electric current therapy 97034 Contrast bath therapy Page 2 of 8
97035 Ultrasound therapy 97036 Hydrotherapy 97039 Physical therapy treatment 97110 Therapeutic exercises 97112 Neuromuscular reeducation 97113 Aquatic therapy/exercises 97116 Gait training therapy 97124 Massage therapy 97139 Physical medicine procedure 97140 Manual therapy 97530 Therapeutic activities 97532 Cognitive skills development 97533 Sensory integration 97535 Self care mngment training 97537 Community/work reintegration 97542 Wheelchair mngment training 97545 Work hardening 97546 Work hardening add-on G0283 Electrical stimulation (unattended) Background: 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 a 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 Page 3 of 8
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, G0283) - 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. It may be considered medically necessary to reduce edema after acute injury. Education for use of lymphedema pump in the home usually requires 1 or 2 sessions. Further treatment of lymphedema by the provider after the educational visits is generally not considered medically necessary. 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 does 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 subacute 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. Ultrasound (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 periarticular structures, and subacute inflammation after injury. Page 4 of 8
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 Reeducation (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/hypertonicity) 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 (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 Page 5 of 8
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, 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 functionbased 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 no 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. Page 6 of 8
19. Work hardening/conditioning (97545-6) 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 by ARBenefits. 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. Signatures of the patient's attending physician and physical therapist. The plan of care should be ongoing, (i.e., updated as the patient's condition changes). Physical and occupational therapy services are considered medically necessary only if there is a reasonable expectation that therapy will achieve measurable improvement in the patient's condition in a reasonable and predictable period of time. The patient should be reevaluated regularly, and there should be documentation of progress made toward the goals of physical therapy. The treatment goals and subsequent documentation of treatment results should specifically demonstrate that therapy services are contributing to such improvement. Application to Products This policy applies to ARBenefits. Consult ARBenefits Summary Plan Description (SPD) for additional information. Page 7 of 8
Last modified by: SCS Date: 12/16/2013 Page 8 of 8