Physical Therapy (PT)

Section: Therapy
Effective Date: March 01, 2020
Revised Date: January 22, 2020
Last Reviewed: January 22, 2020

Description

Physical medicine and rehabilitation is a medical specialty concerned with diagnosis, evaluation, and management of persons with physical impairment and disability. This specialty involves diagnosis and treatment of individuals with painful or functionally limiting conditions, the management of comorbidities and co-impairments.

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

95851 95852 95992 97012 97014 97016 97018
97022 97024 97026 97028 97032 97033 97034
97035 97036 97039 97110 97112 97113 97116
97124 97139 97140 97150 97161 97162 97163
97164 97165 97166 97167 97168 97530 97533
97535 97537 97542 97597 97598 97750 97760
97761 97763 97799 G0283 S8940 S8948 S8950
S8990

Maintenance Therapy

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 Therapy

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.

Procedure Codes

97110 97112 97113 97116 97124 97139 97140

Supervised Modalities

Supervised modalities do not require direct one-on-one individual contact by the provider. These are not time-based codes.

Procedure Codes

 

97012 97014 97016 97018 97022 97024 97026

Vasopneumatic Compression

Treatment is warranted for the following conditions:

  • Edema of the extremities
  • Hematoma of the leg
  • Lymphedema of the arm
  • Lymphedema of the leg
  • Venous insufficiency or venous stasis disorder

Conditions other than those listed above or indicate that an infection is present will be denied as not medically necessary.

Vasopneumatic compression is considered a supervised modality and is not considered time-based. It should be reported only once per treatment session, regardless of the number of areas treated or the length of time required to complete treatment.

97016

Infrared Therapy

The use of infrared and near-infrared light and heat, including monochromatic infrared energy, is considered notmedically necessary when used as a physical medicine modality for the treatment of diabetic and/or non-diabetic peripheral sensory neuropathy and wounds and/or ulcers of the skin and/or subcutaneous tissues.

97026

Constant Attendance Modalities

Constant attendance modalities are those modalities that require direct one-on-one individual contact by the provider. Documentation must include the amount of time spent in providing all aspects of this service.

When two (2) constant attendance modalities are performed at the same time, using one device, the code representing the primary modality must be reported.

Procedure Codes

97032 97033 97034 97035 97036 97039

 

Aquatic Therapy

Aquatic therapy must be performed with the expectation of restoring an individuals level of function that has been lost or reduced by injury or illness. Aquatic therapy performed to maintain a level of function is considered to be a maintenance program.

A provider must have direct (one to one) individual contact when reporting aquatic therapy.

Before beginning an aquatic therapy program, the provider must prepare a treatment plan that includes short-term and long-term goals that the individual can be reasonably expected to accomplish through the aquatic therapy program and the specific methods chosen.

Procedure Codes

 

97034 97113

 

Gait Training

Accepted indications for gait training include,but are not limited to;

  • Foot drop resulting from stroke
  • Herniated disc(s)
  • Ankle, knee and/or hip replacement
  • Traumatic amputations of the toe(s)

Documentation for gait training must demonstrate that the individual's gait was improved either by lengthening the gait or increasing the frequency of cadence lower-extremity.

  • Procedure code 97116 should not be used to report orthotics or prosthetics training.
  • Orthotics training should be reported using procedure codes 97760 and 97763.
  • Prosthetics training should be reported using procedure codes 97761 and 97763.

Procedure Codes

97116

 

Vestibular Rehabilitation Therapy

A vestibular rehabilitation program typically last 45 minutes per session and is prescribed 1-2 times per week. In general, individuals remain in the program 4-8 weeks.

A vestibular rehabilitation program may be considered medically necessary for individuals with vertigo, disequilibrium, and balance deficits related to the following conditions:

  • Peripheral vestibular disorders (e.g., labyrinthitis, neuritis, benign paroxysmal positional vertigo, post vestibular surgical symptoms, and bilateral vestibular loss),
  • Mixed {peripheral and central vestibular disorders, and
  • Central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury)

If none of these conditions are reported, a vestibular rehabilitation program is considered not medically necessary.

Procedure Codes

S9476

Not Medically Necessary

  • Dry Hydro Massage

Experimental/Investigational and, therefore, non-covered,because the safety and effectiveness are not supported by current literature.

  • Electromagnetic Stimulation
  • Equestrian/Hippotherapy
  • Low-Intensity Pulsed Ultrasound (Hands-Free Ultrasound)
  • Horizontal Therapy
  • Low-Level Laser Therapy (Cold Laser Therapy)
  • Phonophoresis

Procedure Codes

97035  97799 S8948

NOTE: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code: 97016

I87.2 I87.8 I87.9 I89.0 I97.2 M79.81 M79.89
Q82.0 R60.0 R60.1 R60.9 S70.10XA S70.11XA S70.12XA
S80.10XA S80.11XA S80.12XA

Covered Diagnosis Codes for Procedure Code – 97116

M51.27 S98.111A S98.111D S98.111S S98.112A S98.112D S98.112S
S98.121A S98.121D S98.121S S98.122A S98.122D S98.122S S98.131A
S98.131D S98.131S S98.132A S98.132D S98.132S S98.141A S98.141D
S98.141S S98.142A S98.142D S98.142S S98.211A S98.211D S98.211S
S98.212A S98.212D S98.212S S98.221D S98.221S S98.221S S98.222A
S98.222D S98.222S Z96.641 Z96.642 Z96.643 Z96.649 Z96.651
Z96.652 Z96.653 Z96.659 Z96.661 Z96.662 Z96.669

Covered Diagnosis Codes for Procedure Code: S9476

G35 H81.10 H81.11 H81.12 H81.13 H81.20 H81.21
H81.22 H81.23 H81.311 H81.312 H81.313 H81.319 H81.391
H81.392 H81.393 H81.399 H81.4 H83.01 H83.02 H83.03
H83.09 I63.30 I63.311 I63.312 I63.313 I63.321 I63.322
I63.323 I63.329 I63.331 I63.332

Professional Statements and Societal Positions Guidelines

NA

ND Committee Review

Internal Medical Policy Commitee 1-22-2020 updated language

Links

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.