Criteria
Coverage for physical medicine is determined according to individual or group customer benefits.
Physical medicine is a covered service when performed with the expectation of restoring the individual's level of function that has been lost or reduced by injury or illness.
Treatment plans must be maintained in the medical record and made available upon request.
A typical session usually consists of up to one (1) hour of rehabilitative therapy which could include up to four (4) physical medicine modalities/procedures and/or units performed on the same date of service, per performing provider.
Services exceeding the limitation will be considered not medically necessary.
Duplicate therapy is considered not medically necessary.
Procedure Codes
4018F |
90901 |
95851 |
95852 |
95992 |
96125 |
97012 |
97014 |
97016 |
97018 |
97022 |
97024 |
97026 |
97028 |
97032 |
97033 |
97034 |
97035 |
97036 |
97039 |
97110 |
97112 |
97113 |
97116 |
97124 |
97129 |
97130 |
97139 |
97140 |
97150 |
97161 |
97162 |
97163 |
97164 |
97530 |
97533 |
97535 |
97537 |
97542 |
97545 |
97546 |
97597 |
97598 |
97750 |
97755 |
97760 |
97761 |
97763 |
97799 |
99374 |
99375 |
99377 |
99378 |
99380 |
G0181 |
G0182 |
G0237 |
G0238 |
G0239 |
G0283 |
S8948 |
S8950 |
S9123 |
S9124 |
S9125 |
S9128 |
S9129 |
S9131 |
T1021 |
T1025 |
T1026 |