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.
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.
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.
Supervised modalities do not require direct one-on-one individual contact by the provider. These are not time-based codes.
Treatment is warranted for the following conditions:
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.
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.
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.
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.
Accepted indications for gait training include,but are not limited to;
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.
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:
If none of these conditions are reported, a vestibular rehabilitation program is considered not medically necessary.
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.
Covered Diagnosis Codes for Procedure Code: 97016
Covered Diagnosis Codes for Procedure Code – 97116
Covered Diagnosis Codes for Procedure Code: S9476
Internal Medical Policy Commitee 1-22-2020 updated language
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.