Physical medicine services performed repetitively to maintain a level of function are not eligible for coverage unless the member has Habilitative services benefits.
A maintenance program consists of activities that preserve the individual's present level of function and prevent regression of that function. These services would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.
Maintenance begins when the therapeutic goals of a treatment plan have been achieved, and no additional functional progress is apparent or expected to occur. Maintenance therapy should be reported under procedure code S8990 (physical or manipulative therapy performed for maintenance rather than restoration) and is not eligible for coverage.
Habilitative Physical Therapy, is care provided for conditions which have limited the normal age appropriate motor, sensory or communication development. To be considered habilitative, functional improvement and measurable progress must be made toward achieving functional goals within a predictable period of time toward an individual’s maximum potential.Functional skills are defined as essential activities of daily life common to all individuals such as dressing, feeding, swallowing, mobility, transfers, fine motor skills, age appropriate activities and communication. Problems such as hearing impairment including deafness, a speech or language impairment, a visual impairment including blindness, serious emotional disturbance, an orthopedic impairment, autism spectrum disorders, traumatic brain injury, deaf-blindness, or multiple disabilities may warrant Habilitative Therapies.
Measurable progress emphasizes accomplishment of functional skills and independence in the contest of the individual’s potential ability as specified within a care plan or treatment goals.
Habilitative/Rehabilitative therapy services must be reported with the 96 or 97 modifiers in conjunction with the appropriate therapy code.
Habilitative therapy is not eligible, unless the member has a habilitative benefit.
*Spinal manipulation is not considered a habilitative service.