FUTURE Local Coverage Determination for Home Health

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FUTURE Local Coverage Determination for Home Health-Physical The...
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FUTURE Local Coverage Determination (LCD):
Home Health-Physical Therapy (L34564)
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Contractor Information
Contractor Name
Palmetto GBA
Contract Number
11004
Contract Type
HHH MAC
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LCD Information
Document Information
LCD ID
L34564
Original ICD-9 LCD ID
L31542
LCD Title
Home Health-Physical Therapy
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UB-04 Manual. OFFICIAL UB-04 DATA SPECIFICATIONS MANUAL,
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Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 10/01/2015
Revision Ending Date
N/A
Retirement Date
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Notice Period Start Date
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Notice Period End Date
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CMS National Coverage Policy
Title XVIII of the Social Security Act, §1862 (a)(1)(A) allows coverage and payment for only those services that are considered to be
reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations.
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42 CFR 409.43, 409.44, 410.61, and 424.22
CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 7, §§30.4, 30.5.1.1, 40, 40.2, 40.2.1 and 40.2.2
CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §§220, 220.2, 220.3, 230, 230.1, 230.5
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations, Chapter 1, Part 1, §§30.1 and 30.1.1
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determination, Chapter 1, Part 2. §§150.5, 160.7, 160.7.1,
160.12, 160.13,160.15 and 160.27
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determination, Chapter 1, Part 3, §170.1
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determination, Chapter 1, Part 4 §§240.3 270.1, 270.6
CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 5, §10.6
CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 32, §11.2
Transmittal AB-02-078, Dated May 28, 2002, Change Request 2083
Transmittal 179, Dated Jan 14, 2014, Change Request 8458
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity
Language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and
coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals
are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In
addition, an administrative law judge may not review a NCD. See §1869(f)(1)(A)(i) of the Social Security Act.
Although there is an overlap in services provided by physical and occupational therapists, this policy addresses only physical therapy.
To be covered as skilled therapy, the services must require the skills of a qualified therapist and must be reasonable and necessary for
the treatment of the patient’s illness or injury as discussed below. Coverage does not turn on the presence or absence of an individual’s
potential for improvement, but rather on the beneficiary’s need for skilled care. Physical therapy services are part of a constellation of
rehabilitative services designed to improve or restore physical functioning as well as to prevent injury, impairments, activity limitations,
participation restrictions and disability following disease, injury or loss of a body part. Impairments, activity limitations and disabilities
are addressed by the examination, evaluation and development of a plan of care that may include implementation of therapeutic
interventions tailored to the specific needs of the individual patient to achieve specific goals and outcomes. The specific interventions
that may be utilized are therapeutic exercises to strengthen muscles, maintain or restore motion, integumentary repair and protection
techniques, physical agents and mechanical modalities such as heat, cold, electrotherpeutic modalities, ultrasound and hydrotherapy,
manual therapy and functional training or retraining an individual to perform the activities of daily living.
Maintenance Therapy
The skills of a qualified therapist (not an assistant) are needed to perform maintenance therapy. Where services that are required to
maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills
of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered physical therapy
services. Further, where the particular patient’s special medical complications require the skills of a qualified therapist to perform a
therapy service safely and effectively that would otherwise be considered unskilled, such services would be covered physical therapy
services.
Coverage of therapy services to perform a maintenance program is not determined solely on the presence or absence of a
beneficiary’s potential for improvement from the therapy, but rather on the beneficiary’s need for skilled care. Assuming all other
eligibility and coverage requirements are met, skilled therapy services are covered when an individualized assessment of the patient’s
clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist (“skilled care”) are
necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient’s
current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and
effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled
care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and
effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance
services will not be covered.
Even if no improvement is expected, under the HH coverage standards, skilled therapy services are covered when an individualized
assessment of the patient’s condition demonstrates that skilled care is necessary for the performance of a safe and effective
maintenance program to maintain the patient’s current condition or prevent or slow further deterioration. Skilled maintenance therapy
may be covered when the particular patient’s special medical complications or the complexity of the therapy procedures require skilled
care.
Restorative/Rehabilitative therapy
In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in
part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the
services.
General Physical Therapy Guidelines:
1. The service of a physical therapist is a skilled therapy service if the inherent complexity of the service is such that it can be
performed safely and/or effectively only by or under the general supervision of a skilled therapist. To be covered, assuming all other
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eligibility and coverage criteria have been met, the services must be reasonable and necessary for the treatment of the patient’s illness
or injury or to the restoration or maintenance of function affected by the patient’s illness or injury. It is necessary to determine whether
individual therapy services are skilled and whether, in view of the patient’s overall condition, skilled management of the services
provided is needed.
2. The development, implementation, management, and evaluation of a patient care plan based on the physician's orders constitute
skilled therapy services when, because of the patient's clinical condition, those activities require the specialized skills, knowledge, and
judgment of a qualified therapist to ensure the effectiveness of the treatment goals and ensure medical safety. Where the specialized
skills, knowledge, and judgment of a therapist are needed to manage and periodically reevaluate the appropriateness of a maintenance
program, such services would be covered, even if the skills of a therapist were not needed to carry out the activities performed as part
of the maintenance program.
3. While a patient's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a patient's diagnosis
or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a
therapist are needed to treat the illness or injury, or whether the services can be carried out by unskilled personnel.
4. A service that is ordinarily considered unskilled could be considered a skilled therapy service in cases where there is clear
documentation that, because of special medical complications, skilled rehabilitation personnel are required to perform the service.
However, the importance of a particular service to a patient or the frequency with which it must be performed does not, by itself, make
an unskilled service into a skilled service.
5. Assuming all other eligibility and coverage criteria have been met, the skilled therapy services must be reasonable and necessary to
the treatment of the patient's illness or injury within the context of the patient's unique medical condition. To be considered reasonable
and necessary for the treatment of the illness or injury:
a. The services must be consistent with the nature and severity of the illness or injury, the patient's particular medical needs,
including the requirement that the amount, frequency, and duration of the services must be reasonable; and
b. The services must be considered, under accepted standards of medical practice, to be specific, safe, and effective treatment
for the patient's condition, meeting the standards noted below. The home health record must specify the purpose of the skilled
service provided.
6. Rehabilitation Services for Vision Impairment
A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve functioning, by therapy, to
improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient’s level of
functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is
critical and should be performed by an occupational or physical therapist.
SPECIFIC PROCEDURE AND MODALITY GUIDELINES:
FABRICATION/APPLICATION OF SPLINTS AND STRAPPING
1. Fabrication and application (as appropriate) of splints and strapping (e.g., the use of elastic wraps, heavy cloth and adhesive tape)
are used to enhance performance of tasks or movements, support weak or ineffective joints or muscles, reduce/correct joint
limitations/deformities, and/or protect body parts from injury. Splints and strapping are often used in conjunction with therapeutic
exercise, functional training, and other interventions and should be selected in the context of a patient’s needs and social/cultural
environments.
2. The physical therapist targets the problems in performance of movements or tasks. The Physical Therapist may select (or fabricate)
the most appropriate device or equipment, fit it and train the patient and/or caregiver(s) in its use and application. The goal is for the
patient to function at a higher level by decreasing functional limitations.
3. The simple application of a commercial splint or brace will not be considered in this section.
Application long arm splint (CPT code 29105):
May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op
reconstruction, contractures or other deformities involving soft tissue.
Application of short arm splint (CPT code 29125 and 29126):
May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op
reconstruction, contractures or other deformities involving soft tissue.
Application of finger splint (CPT code 29130 and 29131):
May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction,
contractures or other deformities involving soft tissue.
Strapping of thorax (CPT code 29200):
May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, fractures,
sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Strapping of low back (CPT code 29799):
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May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures,
Strapping of shoulder (e.g., Velpeau)(CPT code 29240):
May be indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures,
Strapping of elbow or wrist (CPT code 29260):
May be indicated for the elbow and wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of
contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.
Strapping of hand or finger (CPT code 29280):
May be indicated when there is involvement of the hand or finger(s) in the treatment of contusions, dislocations, fractures,
sprain/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft
tissues.
Application of long leg splint (CPT code 29505):
May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations,
fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.
Application of short leg splint (CPT code 29515):
May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures,
sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.
Strapping of hip (CPT code 29520):
May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures,
Strapping of knee (CPT code 29530):
May be indicated when there is involvement of the thigh, knee, or lower leg in the treatment of contusions, dislocations, fractures,
Strapping of ankle and/or foot (CPT code 29540):
May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures,
Strapping of toes (CPT code 29550):
May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Application of Unna boot (CPT code 29580):
A dressing for ulcers resulting from venous insufficiency, consisting of a paste made from gelatin zinc oxide and glycerin which is
applied to the leg then covered with a spiral bandage, this in turn being given a coat of the paste. The process is repeated until
satisfactory rigidity is attained.
Biofeedback training any method and biofeedback training perineal muscles, anorectal or urethral sphincter (CPT codes
90901 and 90911):
The coverage criteria and definition of biofeedback therapy is found in the CMS Internet-Only Manual, Pub 100-03, Medicare National
Coverage Determinations Manual, Chapter 1, Part 1, §§30.1 and 30.1.1
"Biofeedback is a tool utilized by physical therapists to assist with muscle training. This includes facilitation of muscles that are
demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can
be visual or auditory."
Muscle testing, manual (CPT Codes 95831-95834):
The series of codes 95831-95834 are intended to report manual testing of muscles or muscle groups for strength based on grading
scales.
Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk (CPT code 95831):
To use this code for extremity manual muscle testing, every muscle of at least one extremity would need to be tested, with
documentation of why such a thorough assessment was warranted.
Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side (CPT code
95832):
manual testing of hands only
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Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands or including hands (CPT
codes 95833 and 95834):
The measurement of muscle performance using manual muscle testing only.
Range of Motion Measurements (CPT codes 95851 and 95852):
Determination of range of motion using a tape measure, flexible ruler, electronic device or goniometer.
PT Evaluation (CPT code 97001) and PT Re-evaluation (CPT code 97002):
Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services
are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation
is warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to
development of the plan of care, including goals and the selection of interventions. The time spent in evaluation does not count as
treatment time.
1. The initial examination has the following components:
a. The patient history to include prior level of function,
b. Relevant systems review,
c. Tests and measures,
d. Current functional status (abilities and deficits), and
e. Evaluation of patient's, physician's and as appropriate the caregiver's goals
2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of
loss of function, prior functional level, social/environmental considerations, educational level, the patient's overall physical and cognitive
health status, social/cultural supports, psychosocial factors and use of adaptive equipment. Thus, the evaluation reflects the chronicity
or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic
conditions or diseases, and the stability of the condition. Physical therapists also consider the level of the current impairments and the
probability of prolonged impairment, functional limitation, the living environment, prior level of function, the social/cultural supports,
psychosocial factors, and use of adaptive equipment.
3. Initial evaluations or reevaluations may be determined reasonable and necessary even when the evaluation determines that skilled
rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of
treatment are not realized.
4. Reevaluation is periodically indicated during an episode of care when the professional assessment indicates a significant
improvement or decline in the patient’s condition or functional status that was not anticipated in the plan of care. Some regulations and
state practice acts require reevaluation at specific intervals. A reevaluation is focused on evaluation of progress toward current goals
and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services.
5. Reevaluations are appropriate periodically to assess progress toward goals established in the plan of treatment, or to identify and
establish interventions for newly developed impairments at least once every 30 days, for each therapy discipline. A reevaluation may
be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the
physician or the treatment setting at which treatment will be continued.
Maintenance Programs:
MAINTENANCE PROGRAM (MP) means a program established by a therapist that consists of activities and/or mechanisms that will
assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further
deterioration due to a disease or illness.
Skilled therapy services that do not meet the criteria for rehabilitative therapy may be covered in certain circumstances as maintenance
therapy under a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to
prevent or slow further deterioration in function.
Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following
circumstances:
Establishment or design of maintenance programs.
If the specialized skill, knowledge and judgment of a qualified therapist are required to establish or design a maintenance
program to maintain the patient’s current condition or to prevent or slow further deterioration, the establishment or design of a
maintenance program by a qualified therapist is covered. If skilled therapy services by a qualified therapist are needed to instruct
the patient or appropriate caregiver regarding the maintenance program, such instruction is covered. If skilled therapy services
are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or
reassessments are covered.
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Delivery of maintenance programs.
Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the
beneficiary’s need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the
assistance of a family member, caregiver or unskilled personnel. In such situations, coverage is not provided. However, skilled
therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the
specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective
services in a maintenance program. Such skilled care is necessary for the performance of a safe and effective maintenance
program only when (a) the therapy procedures required to maintain the patient’s current function or to prevent or slow further
deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy
procedure or (b) the particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy
service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist
are not ordinarily needed to perform such therapy procedures. Unlike coverage for rehabilitation therapy, coverage of therapy
services to carry out a maintenance program does not depend on the presence or absence of the patient’s potential for
improvement from the therapy.
The deciding factors are always whether the services are considered reasonable, effective treatments for the patient’s condition and
require the skills of a therapist, or whether they can be safely and effectively carried out by non-skilled personnel or caregivers.
Where services that are required to maintain the patient’s current function or to prevent or slow further deterioration are of such
complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the
services would be covered physical therapy services. Further, where the particular patient’s special medical complications require the
skills of a qualified therapist to perform a therapy service safely and effectively that would otherwise be considered unskilled, such
services would be covered physical therapy services.
Hot or Cold Packs therapy (CPT code 97010):
1. Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm and
reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs for sub-acute or chronic
painful conditions.
2. Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist. However, the skills,
knowledge and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular
case, e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or
other complications.
3. Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered
not reasonable and necessary and therefore, are not covered.
Mechanical Traction therapy (CPT code 97012):
1. Traction is generally limited to the cervical or lumbar spine with the hope of relieving pain in or originating from those areas.
2. Specific indications for the use of Mechanical Traction include:
a. Cervical and/or lumbar radiculopathy
b. Back disorders such as disc herniation, lumbago, and sciatica
Vasopneumatic Device Therapy (CPT code 97016):
1. The use of Vasopneumatic Devices may be considered reasonable and necessary for the application of pressure to an extremity for
the purpose of reducing edema.
2. Specific indications for the use of vasopneumatic devices include:
a. Reduction of edema after acute injury
b. Lymphedema of an extremity
c. Education on the use of a lymphedema pump for home use
Note: Further treatment of lymphedema by a physical therapist after the educational visits are generally not reasonable and necessary.
Generally, education can be completed in three visits.
Paraffin Bath (CPT code 97018):
1. Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands, and
feet.
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2. Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist. However, the skills,
knowledge and judgment of a qualified physical therapist might be required in the giving of such treatment or baths in a particular case
(e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other
complications).
Whirlpool (CPT code 97022)
1. Whirlpool baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills,
knowledge and judgment of a qualified physical therapist might be required in such treatments or baths (e.g., where the patient's
condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications). Also, if such
treatments are given prior to but as an integral part of a skilled physical therapy procedure, they would be considered part of the
physical therapy service.
Diathermy Treatment (CPT code 97024):
The coverage criteria and definition of Diathermy Treatment is found in the CMS Internet-Only Manual, Pub 100-03, Medicare National
Coverage Determination, Chapter 1, Part 2, §150.5 and Part 4, §240.3.
Infrared Therapy (CPT code 97026):
The coverage criteria and definition of Infrared Therapy is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National
Coverage Determination, Chapter 1, Part 4, §270.6
Electrical Stimulation Therapy (CPT code 97032):
CPT code 97032 requires "visual, verbal and/or manual contact" (i.e. constant attendance).
Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in
the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low
back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally
recognizable primary disease entity.
Electromagnetic Therapy (HCPCS code G0329):
Electromagnetic therapy criteria and definition are found in the CMS Internet-Only Manual, Pub 100-03, Medicare National Coverage
Determinations Manual, Chapter 1, Part 4, §270.1
Contrast Bath Therapy (CPT code 97034):
1. Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast
baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications
are possible, contrast baths often are used in treatment to decrease edema and inflammation.
2. The use of Contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by
the alternating exposure to heat and cold.
3. Specific indications for the use of contrast baths include:
a. The patient having rheumatoid arthritis or other inflammatory arthritis
b. The patient having reflex sympathetic dystrophy
c. The patient having a sprain or strain resulting from an acute injury
4. Heat treatments and whirlpool baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case,
the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths (e.g., where the
patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications).
Also, if such treatments are given prior to but as an integral part of a skilled physical therapy procedure, they would be considered part
of the physical therapy service.
Ultrasound Therapy (CPT code 97035):
1. Therapeutic Ultrasound is a deep heating modality that produces a sound wave of 0.8 to 3.0 MHz. In the human body ultrasound has
several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately
next to bone can receive an even greater dosage of ultrasound, as much as 30% more. Because of the increased extensibility
ultrasound produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to
cortical bone where they receive a more intense irradiation, ultrasound therapy is an ideal modality for increasing mobility in those
tissues with restricted range of motion.
2. The application of ultrasound is considered reasonable and necessary for patients requiring deep heat to a specific area for
reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.
3. Specific indications for the use of ultrasound application include:
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a. The patient having tightened structures limiting joint motion that require an increase in extensibility
b. The patient having symptomatic soft tissue calcification
c. The patient having neuromas
Note: Ultrasound application is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other
pulmonary condition.
GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES:
1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical
skills and/or services.
2. Use of these procedures require that the services be rendered under the supervision of a qualified physical therapist.
3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented
in the written plan of treatment, effected by the use of each of these procedures, will help define whether these procedures are
reasonable and necessary. Therefore, since any one or a combination of more than one of these procedures may be used in a written
plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal.
4. Services provided concurrently by a physical therapist and occupational therapist may be covered if separate and distinct goals are
documented in the treatment plans.
5. Requires (one on one) direct patient contact
Therapeutic Exercises (CPT code 97110):
1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic
exercise, lumbar stabilization, stretching and strengthening).
2. A physical therapist may use this code when addressing impairments of exercise tolerance due to cardiopulmonary impairments.
Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be
considered for a patient with activity limitations secondary to cardiopulmonary impairments.
3. Therapeutic exercise is considered reasonable and necessary if at least one of the following conditions is present and documented:
a. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint range of motion, gait
problem, balance and/or coordination deficits, abnormal posture, muscle imbalance
b. The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, range of
motion, or endurance as part of activities of daily living training, or reeducation
4. Documentation for therapeutic exercise typically includes objective loss of joint motion, strength, and/or mobility (e.g., degrees of
motion, strength grades, levels of assistance).
Neuromuscular Reeducation (CPT code 97112):
1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g.,
proprioceptive neuromuscular facilitation, BAP’s boards, and desensitization techniques).
2. Neuromuscular reeducation may be considered reasonable and 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, tilt table or standing table,
hypo/hypertonicity) and improvement of motor control and motor learning.
Gait Training Therapy (CPT code 97116):
1. This procedure may be reasonable and necessary for training patients whose walking abilities have been impaired by neurological,
muscular, or skeletal abnormalities or trauma.
2. Specific indications for gait training include:
a. The patient having suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and
ready to begin rehabilitation
b. The patient having recently suffered a musculoskeletal trauma, requiring ambulation re-education
c. The patient having a chronic, progressively debilitating condition for which safe ambulation has recently become a concern
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d. The patient having had an injury or condition that requires instruction in the use of a walker, crutches, or cane
e. The patient having been fitted with a brace/lower limb prosthesis and requires instruction in ambulation
f. The patient having a condition that requires retraining in stairs/steps or chair transfer in addition to general ambulation
3. Gait evaluation and training furnished to a patient whose ability to walk has been impaired by neurological, muscular or skeletal
abnormality require the skills of a qualified physical therapist and constitute skilled physical therapy and are considered reasonable and
necessary if they can be expected to materially improve or maintain the patient's ability to walk or prevent or slow further deterioration
of the patient’s ability to walk. Gait evaluation and training which is furnished to a patient whose ability to walk has been impaired by a
condition other than a neurological, muscular, or skeletal abnormality would nevertheless be covered where physical therapy is
reasonable and necessary to restore or maintain function or to prevent or slow further deterioration.
Massage Therapy (CPT code 97124):
1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various
assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most
effective method of application, because palpation can be used as an assessment as well as a treatment tool.
2. Massage therapy, including effleurage, pétrissage, and/or tapotement (stroking, compression, percussion) may be considered
reasonable and necessary if at least one of the following conditions is present and documented:
a. The patient having paralyzed musculature contributing to impaired circulation
b. The patient having sensitivity of tissues to pressure
c. The patient having tight muscles resulting in shortening and/or spasticity of affected muscles
d. The patient having abnormal adherence of tissue to surrounding tissue
e. The patient requiring relaxation in preparation for neuromuscular re-education or therapeutic exercise
f. The patient having contractures and decreased range of motion
3. In most cases, postural drainage and pulmonary exercises can be carried out safely and effectively by nursing personnel. To be
considered for payment, the physical therapist must identify the intervention that is best suited for the patient, taking into consideration
the patient’s condition and any contraindications that may be present. As there can be an overlap of skills between disciplines, i.e.,
respiratory therapy, skilled nursing and physical therapy, the documentation must clearly support the need for the intervention to be
provided by the physical therapist.
Manual Therapy (CPT code 97140):
1. Joint Mobilization (Peripheral or Spinal)
This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be
reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic
procedure.
2. Soft Tissue Mobilization
This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect
changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of
movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue.
Soft tissue mobilization can be considered reasonable and necessary if at least one of the following conditions is present and
documented:
a. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk
b. treatment being a necessary adjunct to other physical therapy interventions such as 97110, 97112 or 97530
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Orthotics Training (CPT code 97760):
1. This procedure may be considered reasonable and necessary if there is an indication for education on the application of the orthotic,
the orthotic is in the home and the functional use of the orthotic is documented.
2. Generally, orthotic training can be completed in three visits; however, for modification of the orthotic due to healing of tissues,
change in edema, or impairment in skin integrity, additional visits may be required.
3. The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the
same visit as gait training (CPT code 97116) or self-care/home management training (CPT code 97535).
4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases the patient
may not be able to perform this function, but a responsible individual can be trained to use the device.
Prosthetic Training (CPT code 97761):
1. This procedure may be considered reasonable and necessary if there is an indication for education on the application of the
prosthesis, the prosthesis is in the home and the functional use of the prosthetic is documented.
2. The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done
during the same visit as gait training (CPT code 97116) or self care/home management training (CPT code 97535).
3. Periodic revisits beyond the third month would require documentation to support medical necessity.
Therapeutic Activities (CPT code 97530):
1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that
involve movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use
of functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve 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 skills of a physical therapist and are designed to address a specific functional need of the patient. These dynamic activities
must be part of an active treatment plan and be directed at a specific outcome.
2. In order for therapeutic activities to be covered, the following requirements must be met:
a. The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning
b. The patient’s condition being such that he/she is unable to perform therapeutic activities except under the direct supervision of
a physician or physical therapist
c. There being a clear correlation between the type of exercise performed and the patient’s underlying medical condition for
which the therapeutic activities were prescribed
Sensory Integrative Techniques (CPT code 97533):
"Sensory integrative techniques are interventions generally intended for the pediatric and/or neurologically impaired populations. The
focus of these activities is to train the sensory systems to modulate the vast array of incoming sensory stimuli. This is something that is
normally performed without apparent effort. Once the patient/client learns to block the extrasensory 'noise,' the important sensory input
can be processed and a coordinated motor response can be generated."
Self-Care/Home Management Training (CPT code 97535):
The coverage criteria and definition of self-care management training is found in the CMS Internet-Only Manual, Pub 100-03, Medicare
National Coverage Determinations Manual, Chapter 1, Part 3, §170.1
"Self-care/home management training (97535) describes a group of interventions that focuses on activities of daily living skills and
compensatory activities needed to achieve independence” or adapt to an evolving deterioration in health and function. “These include
activities such as dressing, bathing, food preparation, and cooking. The patient/client may require adaptive equipment and/or assistive
technology in the home environment. This code includes training the patient/client and/or caregiver in the use of the equipment."
This code should not be used globally for all home instructions. When instructing the patient in a self-management program, use the
code that best describes the focus of the self-management activity.
Community/Work Reintegration (CPT code 97537,97545, and 97546):
Physical therapy services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable
and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1)(A) of the
Social Security Act.
Wheelchair Management Training (CPT code 97542):
1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who are wheelchair
bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.
2. This procedure is reasonable and necessary only when it requires the skills of a qualified physical therapist and is designed to
address specific needs of the patient. This training must be part of an active treatment plan directed at a specific goal.
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3. The patient and/or caregiver must have the capacity to learn from instructions.
4. Typically three to four sessions should be sufficient to teach the patient and/or caregiver these skills.
5. When billing 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are
attainable by the patient and/or caregiver.
Prosthetic Checkout (CPT Code 97762):
1. These assessments are reasonable and necessary for "established patients who have already received the orthotic or prosthetic
device (permanent or temporary)."
2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device
(e.g., pain, skin breakdown, and falls).
3. These assessments may be reasonable and necessary for determining "the patients response to wearing the device, determining
whether the patient is donning/doffing the device correctly, determining the patient's need for padding, underwrap, or socks and
determining the patient's tolerance to any dynamic forces being applied."
Physical Performance Test or Measurement (CPT code 97750):
This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions when such tests are needed
to formulate or evaluate a specific treatment plan, or to determine a patient’s functional capacity.
Assistive Technology Assessment (CPT code 97755)
This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing
and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the
patients status since the last visit and whether the planned procedure or service should be modified. Based on these assessment data,
the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or reevaluation is
indicated.
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Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill
Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage
is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
032x
Home Health - Inpatient (plan of treatment under Part B only)
Revenue Codes:
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In
most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are
equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by
Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
0420
Physical Therapy - General Classification
0421
Physical Therapy - Visit
0424
Physical Therapy - Evaluation or Re-evaluation
0429
Physical Therapy - Other Physical Therapy
CPT/HCPCS Codes
Group 1 Paragraph:
As of July 1999, Physical Therapists must report time spent with the patient in 15-minute increments. The
following code should be used by Physical Therapy:
Group 1 Codes:
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G0151
HHCP-serv of pt,ea 15 min
Group 2 Paragraph:
Other CPT codes found in this policy are for informational and descriptive use only.
Group 2 Codes:
29105
Apply long arm splint
29125
Apply forearm splint
29126
Apply forearm splint
29130
Application of finger splint
29131
Application of finger splint
29200
Strapping of chest
29240
Strapping of shoulder
29260
Strapping of elbow or wrist
29280
Strapping of hand or finger
29505
Application long leg splint
29515
Application lower leg splint
29520
Strapping of hip
29530
Strapping of knee
29540
Strapping of ankle and/or ft
29550
Strapping of toes
29580
Application of paste boot
29799
Casting/strapping procedure
90901
Biofeedback train any meth
90911
Biofeedback peri/uro/rectal
95831
Limb muscle testing manual
95832
Hand muscle testing manual
95833
Body muscle testing manual
95834
Body muscle testing manual
95851
Range of motion measurements
95852
Range of motion measurements
97001
Pt evaluation
97002
Pt re-evaluation
97010
Hot or cold packs therapy
97012
Mechanical traction therapy
97016
Vasopneumatic device therapy
97018
Paraffin bath therapy
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97022
Whirlpool therapy
97024
Diathermy eg microwave
97026
Infrared therapy
97032
Electrical stimulation
97034
Contrast bath therapy
97035
Ultrasound therapy
97110
Therapeutic exercises
97112
Neuromuscular reeducation
97116
Gait training therapy
97124
Massage therapy
97140
Manual therapy 1/> regions
97530
Therapeutic activities
97533
Sensory integration
97535
Self care mngment training
97537
Community/work reintegration
97542
Wheelchair mngment training
97545
Work hardening
97546
Work hardening add-on
97750
Physical performance test
97755
Assistive technology assess
97760
Orthotic mgmt and training
97761
Prosthetic training
97762
C/o for orthotic/prosth use
G0329
Electromagntic tx for ulcers
ICD-10 Codes that Support Medical Necessity
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N/A
Group 1 Codes:
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ICD-10 CODE
DESCRIPTION
A18.01
Tuberculosis of spine
B91
Sequelae of poliomyelitis
D48.1
Neoplasm of uncertain behavior of connective and other soft tissue
E08.40
Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified
E08.42
Diabetes mellitus due to underlying condition with diabetic polyneuropathy
E08.44
Diabetes mellitus due to underlying condition with diabetic amyotrophy
E08.52
Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with
gangrene
E09.40
Drug or chemical induced diabetes mellitus with neurological complications with diabetic
neuropathy, unspecified
E09.42
polyneuropathy
E09.44
amyotrophy
E09.52
Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with
gangrene
E10.40
Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.42
Type 1 diabetes mellitus with diabetic polyneuropathy
E10.44
Type 1 diabetes mellitus with diabetic amyotrophy
E10.52
Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E11.40
Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.42
Type 2 diabetes mellitus with diabetic polyneuropathy
E11.44
Type 2 diabetes mellitus with diabetic amyotrophy
E11.52
Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene
E13.40
Other specified diabetes mellitus with diabetic neuropathy, unspecified
E13.42
Other specified diabetes mellitus with diabetic polyneuropathy
E13.44
Other specified diabetes mellitus with diabetic amyotrophy
E13.52
Other specified diabetes mellitus with diabetic peripheral angiopathy with gangrene
G04.1
Tropical spastic paraplegia
G14
Postpolio syndrome
G24.01
Drug induced subacute dyskinesia
G24.02
Drug induced acute dystonia
G24.09
Other drug induced dystonia
G24.2
Idiopathic nonfamilial dystonia
G24.3
Spasmodic torticollis
G24.8
Other dystonia
G25.82
Stiff-man syndrome
G31.85
Corticobasal degeneration
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G51.0
Bell's palsy
G54.0
Brachial plexus disorders
G54.1
Lumbosacral plexus disorders
G54.2
Cervical root disorders, not elsewhere classified
G54.3
Thoracic root disorders, not elsewhere classified
G54.4
Lumbosacral root disorders, not elsewhere classified
G54.5
Neuralgic amyotrophy
G54.6
Phantom limb syndrome with pain
G54.7
Phantom limb syndrome without pain
G54.8
Other nerve root and plexus disorders
G55
Nerve root and plexus compressions in diseases classified elsewhere
G56.01
Carpal tunnel syndrome, right upper limb
G56.02
Carpal tunnel syndrome, left upper limb
G56.11
Other lesions of median nerve, right upper limb
G56.12
Other lesions of median nerve, left upper limb
G56.21
Lesion of ulnar nerve, right upper limb
G56.22
Lesion of ulnar nerve, left upper limb
G56.31
Lesion of radial nerve, right upper limb
G56.32
Lesion of radial nerve, left upper limb
G56.41
Causalgia of right upper limb
G56.42
Causalgia of left upper limb
G56.81
Other specified mononeuropathies of right upper limb
G56.82
Other specified mononeuropathies of left upper limb
G57.01
Lesion of sciatic nerve, right lower limb
G57.02
Lesion of sciatic nerve, left lower limb
G57.11
Meralgia paresthetica, right lower limb
G57.12
Meralgia paresthetica, left lower limb
G57.21
Lesion of femoral nerve, right lower limb
G57.22
Lesion of femoral nerve, left lower limb
G57.31
Lesion of lateral popliteal nerve, right lower limb
G57.32
Lesion of lateral popliteal nerve, left lower limb
G57.41
Lesion of medial popliteal nerve, right lower limb
G57.42
Lesion of medial popliteal nerve, left lower limb
G57.51
Tarsal tunnel syndrome, right lower limb
G57.52
Tarsal tunnel syndrome, left lower limb
G57.61
Lesion of plantar nerve, right lower limb
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G57.62
Lesion of plantar nerve, left lower limb
G57.71
Causalgia of right lower limb
G57.72
Causalgia of left lower limb
G57.81
Other specified mononeuropathies of right lower limb
G57.82
Other specified mononeuropathies of left lower limb
G57.91
Unspecified mononeuropathy of right lower limb
G57.92
Unspecified mononeuropathy of left lower limb
G58.0
Intercostal neuropathy
G58.7
Mononeuritis multiplex
G60.0
Hereditary motor and sensory neuropathy
G60.1
Refsum's disease
G60.2
Neuropathy in association with hereditary ataxia
G60.3
Idiopathic progressive neuropathy
G60.8
Other hereditary and idiopathic neuropathies
G61.0
Guillain-Barre syndrome
G70.81
Lambert-Eaton syndrome in disease classified elsewhere
G71.11
Myotonic muscular dystrophy
G71.12
Myotonia congenita
G71.13
Myotonic chondrodystrophy
G71.14
Drug induced myotonia
G71.19
Other specified myotonic disorders
G72.41
Inclusion body myositis [IBM]
G72.49
Other inflammatory and immune myopathies, not elsewhere classified
G73.1
Lambert-Eaton syndrome in neoplastic disease
G80.3
Athetoid cerebral palsy
G81.01
Flaccid hemiplegia affecting right dominant side
G81.02
Flaccid hemiplegia affecting left dominant side
G81.03
Flaccid hemiplegia affecting right nondominant side
G81.04
Flaccid hemiplegia affecting left nondominant side
G81.11
Spastic hemiplegia affecting right dominant side
G81.12
Spastic hemiplegia affecting left dominant side
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ICD-10 Codes that DO NOT Support Medical Necessity
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DESCRIPTION
XX000
Not Applicable
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General Information
Associated Information
Documentation Requirements
1. Documentation supporting the medical necessity should be legible, relevant and sufficient to justify the services billed. This
documentation must be made available to the A/B MAC upon request.
2. The plan of treatment written by the patient’s physician after any needed consultation with the qualified physical therapist and
signed by the physician. This must be in the patient’s medical record and made available to the A/B MAC upon request.
3. When documenting family member/caregiver training and education, the documentation should include the person(s) being trained
and the effectiveness of the training and education. The training and education should be an adjunct to the active therapy with the
patient.
4. OASIS data should support the medical necessity of the services documented in the medical records. For therapy services the
OASIS MO2200 should be filled out completely and filed with the State Repository. An updated and completed OASIS for the billing
period should be on file with the State Repository and in the patient’s medical records to be made available to the A/B MAC upon
request.
5. The home health clinical notes must document as appropriate:
• the history and physical exam pertinent to the day’s visit, (including the response or changes in behavior to previously administered
skilled services) and the skilled services applied on the current visit, and
• the patient/caregiver’s response to the skilled services provided, and
• the plan for the next visit based on the rationale of prior results,
• a detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences,
• the complexity of the service(s) to be performed, and
• any other pertinent characteristics of the beneficiary or home
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Functional reporting uses nonpayable G-codes and related modifiers to convey information about the patient’s functional status at
specified points during treatment. This functional data reporting is effective for therapy services with dates of service on and after
January 1, 2013. The functional reporting requirements apply to the therapy services furnished by the following providers: CAHs,
SNFs, CORFs, rehabilitation agencies, and HHAs (where a beneficiary is not under a home health plan of care.
In the medical record, functional documentation must be included:
at the beginning of a therapy episode of care
in the therapy plan of care as functional limitations and expressed as part of the patient’s long term goals
as the patient’s current status, projected goal, and discharge status (for each date of service)
in the progress report at the end of each progress reporting period, i.e. at least once every tenth treatment day
at the time of discharge, on the discharge note or summary
when an evaluation or re-evaluation is furnished and billed
for reporting that a particular functional limitation is ended, but further therapy is required
when reporting is begun for a new or different functional limitation during the same therapy episode
Documentation of functional reporting in the medical record of therapy services must be completed by the clinician furnishing the
therapy services:
The qualified therapist furnishing the therapy services
The physician/NPP personally furnishing the therapy services
The qualified therapist furnishing services incident to the physician/NPP
The physician/NPP for incident to services furnished by qualified personnel, who are not qualified therapists.
The qualified therapist furnishing the PT, OT, or SLP services in a CORF
6. Documentation should justify:
- the individual is under the care of a physician or non-physician practitioner
- services require the skills of a therapist
- services are of the appropriate type, frequency, intensity and duration for the individual needs of the patient
7. For restorative/rehabilitative therapy documentation should establish:
- variables that influence the patient's condition
- services provided at the time of treatment
- objective measurements that the patient is making progress toward goals. If it becomes apparent at some point that the goal set for
the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this,
and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of
skilled services.
- clinical rationale for continued treatment and/or reasons for lack of progress
- recommended changes to the plan of care
- ongoing reassessment of the patients response to treatment
8. Maintenance Program
• It is expected that in situations where the maintenance program is performed to maintain the patient’s current condition, such
documentation would serve to demonstrate the program’s effectiveness in achieving this goal.
•Where the particular patient’s special medical complications require the skills of a qualified therapist to perform a therapy service
safely and effectively that would otherwise be considered unskilled, such services would be covered physical therapy services.
• If it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself
should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the
treatment goal as revised continues to require the provision of skilled services.
• By the same token, the treatment goal itself cannot be modified retrospectively, e.g., when it becomes apparent that the initial
treatment goal of restoration is no longer a reasonable one, the provider cannot retroactively alter the initial goal of treatment from
restoration to maintenance.
9. The physician and non-physician’s documentation must be sufficient for determining the appropriateness of coverage.
10. While a patient is under a restorative physical therapy program, the physical therapist should regularly reevaluate the patient's
condition and adjust any exercise program the patient is expected to carry out alone or with the aid of supportive personnel to
maintain the function being restored.
Evaluation/Reevaluations
The physician and/or physical therapist's evaluation/re-evaluation assess the area for which physical therapy treatment is being
planned. It must be completed prior to beginning therapy. Evaluations must contain the following information:
1. Reason for referral
2. Diagnosis/condition being treated
3. Past level of function (be specific)
4. Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring
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progress.
5. Current level of function
6. Objective measurements such as strength, ROM, pain, ADL level, or edema
7. Treatment techniques/modalities selected for treating current illness or injury
8. Limitations which may influence the length of treatment
9. Short and long term goals stated in objective measurable terms, and their expected date of accomplishment
10. Frequency and duration of therapy
11. Re-assessments must be performed at least every 30 days by a qualified physical therapist. The 30 day clock begins with the first
therapy’s visit/assessment/measurement/documentation (of the physical therapist).
Plan of Treatment
Services are to be furnished according to a written plan of treatment determined by the physician after any needed consultations with
the qualified physical therapist and signed and dated by the physician after an appropriate assessment (evaluation) of the condition
(illness or injury) is completed. The plan of treatment must be completed before active therapy begins. The plan of treatment must be
signed by the referring or attending physician prior to billing the service to Medicare. The written plan of treatment may not be altered
by an physical therapist. *Electronic signatures are acceptable if the proper documentation is submitted to the J11 MAC. However,
stamped dates are not allowed.
1. The written plan of care must contain the following elements:
a. Diagnosis being treated and the specific problems identified that are to be addressed
b. Treatment techniques/modalities or procedures being used for specific problem to attain the stated goals
c. Specific functional goals for therapy in objective measurable terms (patient/caregiver maybe included or taken into
consideration)
d. Amount, frequency, and duration of therapeutic services
e. Rehabilitation potential - therapists/physician's expectation of the patient's ability to meet the goals at initiation of treatment
(patient and, when appropriate, caregiver goals may be incorporated)
Treatment Note/Clinical Notes/Progress Notes
1. A treatment/clinical/progress note should be written for each visit using objective measurements and functional accomplishments. It
should contain the objective status of the patient, a description of the services performed, the patient's response to the services and
the relation toward the treatment goals.
2. The treatment/clinical/progress note should document any treatment variations with the associated rationale. It is expected that the
home health records for every visit will reflect the need for the skilled medical care provided. These clinical notes are also expected to
provide important communication among all members of the home care team regarding the development, course and outcomes of the
skilled observations, assessments, treatment and training performed. Taken as a whole then, the clinical notes are expected to tell the
story of the patient’s achievement towards his/her goals as outlined in the Plan of Care.
3. The treatment/clinical/progress notes for each treatment visit detailing the skilled services provided. These notes may also serve as
progress reports when required information is included in the notes. The treatment notes should be written using objective
measurements and functional accomplishments. Use statements which demonstrate the patient's response to the therapy such as:
a. "Able to perform exercises as prescribed for 15 reps"
b. "Able to safely transfer from bed to toilet with standby assistance"
c. "Can now abduct shoulder 120 degrees"
d. "Able to don a pull over shirt with minimal assistance"
4. Avoid terms such as:
a. "Doing well"
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b. "Improving"
c. "Less pain"
d. "Increased range of motion"
e. "Increased strength"
f. "Tolerated treatment well"
g. "Continue with POC"
Certification/Re-certification
1. The certifying physician must document that he or she had a face-to-face encounter with the patient. The encounter must occur no
more than 90 days prior to the home health start of care date or within 30 days after the start of care.
2. Certifications and re-certifications by the physician, must be on file and available to the A/B MAC when the request for payment is
forwarded.
3. Certifications are required upon initiation of therapy and at least every 60 days thereafter for Home Health.
4. The referring/attending physician establishes or reviews the plan of treatment and makes the necessary certifications and he/she
must sign (including professional identity) and date all certifications/re-certifications.
5. Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of
time, or the need to establish a safe and effective maintenance program.
Utilization Guidelines
Whether the plan is rehabilitative/restorative or maintenance should be indicated on the CMS-485 or on the OASIS M1800-M1910
with reference to ADL/IADL's and current ability.
Sources of Information and Basis for Decision
A Payer’s Guide to Interventions Provided by Physical Therapists and related CPT Coding. 2nd Ed. Alexandria, Va: American
Physical Therapy Association; 2006.
American Medical Association. CPT Assistant. December 2003;13(12):6.
American Medical Association. CPT Assistant. February 2004;14(2):5-6.
American Medical Association. CPT Assistant. July 2004; 14(7):14.
American Medical Association. CPT Assistant. August 2006;16(8):11.
American Medical Association. CPT Assistant. February 2007;17(2):8-9,12.
American Medical Association. Coding Consultation. April 2002:18.
Birrer, R. Sports Medicine for the Primary Care Physician. (2nd ed.). Boca Raton: CRC Press; 1994.
Delisa JA (Ed). Rehabilitation Medicine: Principles and Practice. The Jour of Hand Surg.1994;19:707.
Guide to Physical Therapist Practice. Phys Ther. 1997;77:1163-1650.
International Classification of Functioning, Disability and Health: ICF. Geneva: World Health Organization, 2001.
Kotte F, Lehmann J. Krusen’s Handbook of Physical Medicine and Rehabilitation. 4th ed. Philadelphia, Pa: W.B. Saunders Company;
1990.
Matsumura B, Ambrose A. Balance in the Elderly. Clin in Geriat Med. 2006;22:395-412.
Studenski S, Duncan P, Maino J. Principles of Rehabilitation in Older Patients. In: Hazzard WR, Blass JP, Ettinger WH, et al (eds).
Principles of Geriatric Medicine and Gerontology. New York, NY: McGraw Hill Companies; 1999:Chapter 31.
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Revision History Information
Please note: Most Revision History entries effective on or before 01/24/2013 display with a Revision History Number of
"R1" at the bottom of this table. However, there may be LCDs where these entries will display as a separate and distinct
row.
REVISION
HISTORY DATE
REVISION
HISTORY
NUMBER
10/01/2015
R3
REVISION HISTORY EXPLANATION
Under CMS National Coverage Policy
added reference to Pub 100-02, Chapter
7 section 30.5.1.1 regarding
Face-To-Face requirements; added
reference to Pub 100-02, Chapter 15,
Sections 220, 220.2, 230, 230.1 and
230.5; added reference to CR 8458;
added reference to Pub 100-04, Chapter
5, Section 10.6; added reference to Pub
100-03, Chapter 1, part 4, Section 240.3
and removed 280.13; added reference
to 42 CFR sections 409.43, 409.44,
410.61 and 424.22. Under Coverage
Indications, Limitations and /or
Medical Necessity made several
grammatical and punctuation changes,
added statement from CR 2083
REASON(S) FOR CHANGE
Provider Education/Guidance
3/16/2015 4:36 PM
21 of 22
regarding Vision Impairment "A Medicare
beneficiary with vision loss may be
eligible for rehabilitation services
designed to improve functioning, by
therapy, to improve performance of
activities of daily living, including
self-care and home management skills.
Evaluation of the patient’s level of
functioning in activities of daily living,
followed by implementation of a
therapeutic plan of care aimed at safe
and independent living, is critical and
should be performed by an occupational
or physical therapist", removed the
sentence "the coverage criteria and
definition of rehabilitative services for
vision impairment (Low Vision) is found
in transmittal AB-02-078, dated May 28,
2002, Change Request 2083" as it is
now in the policy, corrected the spelling
of Velpeau for CPT code 29240, under
General Guidelines for Therapeutic
Procedures added "qualified" to physical
therapist, added Sensory Integrative
Techniques (CPT code 97533) "Sensory
integrative techniques are interventions
generally intended for the pediatric
and/or neurologically impaired
populations. The focus of these activities
is to train the sensory systems to
modulate the vast array of incoming
sensory stimuli. This is something that is
normally performed without apparent
effort. Once the patient/client learns to
block the extrasensory 'noise,' the
important sensory input can be
processed and a coordinated motor
response can be generated", Under
Wheelchair Management Training added
"qualified" physical therapist; added
Assistive Technology Assessment (CPT
code 97755) This assessment requires
professional skill to gather data by
observation and patient inquiry and may
include limited objective testing and
measurement to make clinical judgments
regarding the patient's condition(s).
Assessment determines, e.g., changes
in the patients status since the last visit
and whether the planned procedure or
service should be modified. Based on
these assessment data, the professional
may make judgment about progress
toward goals and/or determine that a
more complete evaluation or
reevaluation is indicated.
Under Bill Type Codes removed 033x
per Change Request 8244.
Under Group 2 CPT/HCPCS Codes
added 97533.
Under Associated Information added
entire section on Functional Reporting
and reworded the Utilization Guidelines
to read Whether the plan is
rehabilitative/restorative or maintenance
should be indicated on the CMS-485 or
on the OASIS M1800-M1910 with
current rerence to ADL/IADL's and
current ability.
Under Sources of Information and
Basis for Decision corrected all
sources to AMA formatting, added
references for CPT assistant x 5, coding
consultation, ICF manual, A Payer's
Guide, and Balance in the Elderly.
10/01/2015
R2
Under Coverage Indications,
Limitations and/or Medical Necessity,
Typographical Error
3/16/2015 4:36 PM
22 of 22
General Physical Therapy Guidelines:
removed "A service that is ordinarily
considered unskilled could be
considered a skilled therapy service in
cases where there is clear
documentation that, because of special
medical complications, skilled
rehabilitation personnel are required to
perform the service. However, the
importance of a particular service to a
patient or the frequency with which it
must be performed does not, by itself,
make an unskilled service into a skilled
service"
and in Maintenance Programs:
removed 5. Where services that are
required to maintain the patient’s current
function or to prevent or slow further
deterioration are of such complexity and
sophistication that the skills of a qualified
therapist are required to perform the
procedure safely and effectively, the
services would be covered physical
therapy services. Further, where the
particular patient’s special medical
complications require the skills of a
qualified therapist to perform a therapy
service safely and effectively that would
otherwise be considered unskilled, such
services would be covered physical
therapy services. as these were
duplicate statements.
10/01/2015
R1
Under ICD-10 Codes That Support
Medical Necessity-Group 1 ICD-10
Codes effective 06/29/2014, ICD-10
code description verbiage was revised
due to the 2014 & 2015 Annual ICD-10
Code Update for the following: M08.88,
M12.08, M50.11, M50.21, M84.58XS.
Provider Education/Guidance
Revisions Due To ICD-10-CM
Code Changes
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Associated Documents
Attachments
N/A
Related Local Coverage Documents
Article(s)
A53053 - CPT Code 97755 - Assistive Technology Assessment
A53058 - Physical Therapy for Home Health
Related National Coverage Documents
N/A
Public Version(s)
Updated on 03/06/2015 with effective dates 10/01/2015 - N/A
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Keywords
Physical Therapy
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FUTURE Local Coverage Determination for Home Health

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