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LCD
ID Number
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L17639
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LCD
Title
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Physical Medicine and
Rehabilitation Modalities
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Contractor's
Determination Number
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L17639
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AMA
CPT / ADA
CDT Copyright Statement
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CPT codes,
descriptions and other data only are copyright 2007 American Medical
Association (or such other date of publication of CPT). All Rights
Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology,
(CDT) (including procedure codes, nomenclature, descriptors and other data
contained therein) is copyright by the American Dental Association. © 2002,
2004 American Dental Association. All rights reserved. Applicable
FARS/DFARS apply.
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CMS
National Coverage Policy
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Title XVIII of the
Social Security Act, section 1862(a)(1)(A). This section allows coverage
and payment for only those services that are considered to be reasonable
and medically necessary.
Title XVIII of the Social Security Act, section 1861(g),(p),(s)and(u). This
section establishes definitions for services, institutions, and other
Medicare terms.
42 Code of Federal Regulations (42CFR) Part 409 includes the definition of
‘reasonable and necessary’ therapy services that applies to both Part A and
Part B services.
42 Code of Federal Regulations (42CFR) Part 410 describes the benefits to
be paid under Medicare Part B, including outpatient physical therapy
services.
42 Code of Federal Regulations (42CFR) Part 411 describes those specific
services excluded from Medicare or that are subject to limitations on
payment.
42 Code of Federal Regulations (42CFR) Part 414 describes the provisions of
payment for Part B services under a fee schedule and for payments for
prosthetics and orthotics.
42 Code of Federal Regulations (42CFR) Part 420 describes specific Medicare
program integrity requirements to prevent fraud and abuse. It also sets
forth appeal rights of providers.
42 Code of Federal Regulations (42CFR) Part 421 identifies the activities
required of the fiscal intermediaries and carriers that process Medicare
claims.
42 Code of Federal Regulations (42CFR) Part 424 describes the conditions
for Medicare payment, including those governing Part B outpatient physical
therapy services. In particular, it sets forth certification, plan of
treatment, and CORF requirements.
42 Code of Federal Regulations (42CFR) Part 484 includes the personnel
qualifications that Medicare requires for identification as a physical
therapist or a physical therapy assistant.
CMS Manual System, Medicare General Information, Eligibility, and
Entitlement Manual (Pub. 100-1), Chapter 4, Section 50.
CMS Manual System, Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15,
Section 220 - Coverage of Outpatient Physical Therapy, Occupational Therapy
and Speech - Language Pathology Services Under Medical Insurance and
Section 230 - Payable Rehabilitation Services.
CMS Manual System, Medicare Claims Processing Manual (Pub. 100-4), Chapter
5 - Part B Outpatient Rehabilitation and CORF Services and Chapter 32,
Section 10 - Wound Treatments.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 150.1 – Manipulation.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 240.3 – Heat Treatment, Including the use of
Diathermy and Ultra-Sound for Pulmonary Conditions.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 160.2 – Treatment of Motor Function Disorders
with Electric Nerve Stimulation – Not Covered.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 30.1 – Biofeedback Therapy.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 270.4 – Treatment of Decubitus Ulcers.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 150.5 – Diathermy Treatment.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 160.3 and 160.7.1 – Assessing Patient’s
Suitability for Electrical Nerve Stimulation Therapy.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 150.8 – Fluidized Therapy Dry Heat for Certain
Musculoskeletal Disorders.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 160.15 – Electrotherapy for Treatment of Facial
Nerve Paralysis (Bell’s Palsy).
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 150.4 and 160.12 – Neuromuscular Electrical
Nerve Stimulation (NMES) in the Treatment of Disuse Atrophy.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 30.5 – Transcendental Meditation.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 160.16 – Vertebral Axial Decompression (VAX-D).
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 270.1.1 – Electrical Stimulation in the
Treatment of Wounds.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 10.2 – Transcutaneous Electrical Nerve
Stimulation (TENS) for Acute Post-Operative Pain.
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 160.13 – Supplies Used in the Delivery of
Transcutaneous Electrical Nerve Stimulation (TENS) and Neuromuscular
Electrical Stimulation (NMES).
CMS Manual System, Medicare National Coverage Determinations Manual (Pub.
100-3), Chapter 1, Section 270 - Wound Treatment.
If the Medicare National Coverage Determinations Manual (Pub. 100-3) is not
available online, please refer to the paper-based Coverage Issues Manual.
CMS Manual System, Medicare Program Integrity Manual (Pub. 100-8), Chapter
3, Section 4.1.1.
CMS Manual System, Medicare Benefit Policy Manual, (Pub. 100-02)
Chapter 15, Section 220
Program Memorandum AB-03-018: Implementation of the Financial Limitation
for Outpatient Rehabilitation Services.
Program Memorandum AB-02-161: Coverage and Billing Requirements for
Electrical Stimulation for the Treatment of Wounds.
Program Memorandum AB-02-156: Coverage and Billing for Neuromuscular
Electrical Stimulation (NEMS).
Program Memorandum AB-02-078: Provider Education Article: Medicare Coverage
of Rehabilitation Services for Beneficiaries With Vision Impairment.
Program Memorandum AB-01-68: Consolidation of Program Memorandums for
Outpatient Rehabilitation Therapy Services.
Program Memorandum AB-00-14: Questions and Answers Regarding the
Prospective Payment System (PPS) for Outpatient Rehabilitation Services and
Physical Medicine Current Procedural Terminology (CPT) Coding Guidance.
CMS Transmittal 88, Change Request 5921
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Primary Geographic
Jurisdiction
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New
Jersey
Tennessee
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Secondary Geographic
Jurisdiction
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Alaska
Alabama
Arkansas
Arizona
California
Colorado
Connecticut
Florida
Georgia
Hawaii
Iowa
Idaho
Illinois
Indiana
Kansas
Kentucky
Louisiana
Massachusetts
Maryland
Maine
Michigan
Minnesota
Missouri
Mississippi
North Carolina
North Dakota
Nebraska
New Jersey
New Mexico
Nevada
New York
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
Tennessee
Texas
Utah
Virginia
Vermont
Washington
Wisconsin
West Virginia
Wyoming
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Oversight
Region
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Region IV
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Original
Determination Effective Date
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For services performed
on or after 09/30/2004
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Original
Determination Ending Date
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Revision
Effective Date
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For services performed
on or after 01/01/2008
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Revision
Ending Date
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Indications
and Limitations of Coverage and/or Medical Necessity
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General Modality
Guidelines
Physical Therapy Modalities are those services that involve the application
of a physical agent to produce a therapeutic change in the structural
elements of the patient (typically muscle, bone, joints, ligaments and
skin). The use of modalities as stand-alone treatments are rarely
therapeutic and usually not required or indicated as the sole treatment
approach to a patient’s condition. Therapeutic exercises and activities
have proven to be an essential part of a therapeutic plan of care; a
treatment plan should therefore not consist solely of modalities, but
should include therapeutic procedures. Even in the unusual situation in
which a patient has an acute condition and has difficulty enduring any
therapeutic manipulation, it is expected that some therapeutic procedures
will be employed as, in their absence, there is neither a medical need for
the skilled services of the therapist nor a likelihood of sustained
clinical benefit. The use of modalities in the absence of a therapeutic
procedure during the same session will therefore be considered NOT
MEDICALLY NECESSARY. Exceptions to this "isolated modality"
limitation may RARELY be considered on an exceptional basis IF the service
is provided without therapy on the specific order of a physician AND
clinical documentation is submitted to justify that use. The use of
modalities in the setting of wound care is discussed separately.
Hot or cold packs are commonly self-administered by patients and do not
require the unique skills of a licensed therapist. For the purposes of the
following discussions, a distinction is made between the unskilled application
of a hot or cold pack and any skilled application of a thermal or
mechanical modality. The unskilled application of a hot/cold pack is
frequently required as part of therapeutic intervention and is in no way
constrained by this policy. Conversely, though, it is expected that medical
necessity for a skilled modality includes the demonstration that the skilled
application of the modality is necessary over and above the need for an
(unskilled) hot/cold pack. Modalities will not be considered to be medically
necessary when the skilled services of the physical therapist are not
required or when the application of a simple hot or cold pack would be
considered equally appropriate.
Since the function of modalities is to facilitate the performance of the
therapeutic intervention, modalities share a common usage. Although the
medical record should always document the need for any modality, this is
particularly true when more than one modality is used on a single day. When
more than one skilled modality is required on a single day,
the second will only be considered medically necessary with specific
justification in the medical record. Although this does not require the
express order of the referring physician, involvement of the ordering
physician in the decision to use multiple modalities adds considerably to
the clinical justification. Documentation to support this need for a second
modality does not need to be submitted with the claim but should be
available in case the record is selected for medical review.
More than two skilled modalities will not be considered
medically necessary on a single day. Exceptions to the TWO modality
limit may RARELY be considered on an exceptional basis IF the multiple
modalities are provided on the specific order of a physician AND clinical
documentation is submitted to justify that use.
Multiple modalites that accomplish the same result (e.g. hot packs and
infrared, whirlpool and Hubbard tank) will not both be considered medically
necessary.
Because of the interchangeability of many modalities, the treatment of
multiple body areas does not change the limitation on the number of
modalities that is medically necessary in a single day. If one thermal
modality, for example, is applied to one body area, a second thermal modality
applied to a different body part would only be considered medically
necessary when specific documentation supported the conclusion that a
single modality could be be safely and efficaciously used on both body
part. A second modality of a different type (e.g. traction and heat) is
less likely to be considered interchangeable but the need for the
documentation to support the need for two distinct modalities in the same
patient remains in effect.
Finally, for the purposes of applying limitations on utilization, similar
skilled modalities are considered interchangeable. A patient who fails
to respond to one thermal modality, for example, should be rapidly switched
to a different thermal modality, but a patient who then responds to and
completes a full course of one modality will also be considered as having
completed a full course of all similar skilled modalities when they
are used for the same indication. It is Riverbend's expectation that
all modalities are most commonly used as adjuncts during the initiation of
therapy or following specific changes, typically for brief periods before
being discontinued when no longer necessary. It is not expected that all
patients will demonstrate a need for skilled modalities (i.e.
adjunctive treatment beyond the unskilled application of hot and cold
packs) or that patients would all require the use of modalities for the
same length of time (e.g. by protocol).
Specific Modalities
CPT 97010 - Hot or Cold Packs Therapy
Hot or cold packs are commonly self-administered by patients and do not
require the unique skills of a licensed therapist. Hot and cold packs are a
covered service and are incorporated (adjunctive) as an element of a
therapeutic procedure; however the skilled application of the pack
is not medically necessary and is therefore not separately reimbursable. As
unskilled and bundled services, hot and cold packs do not contribute to the
two modality limit. However, in assessing medical necessity for thermal
modalities, it is expected not only that a thermal modality is medically
necessary but also that the skilled modality is required over and above the
benefit obtainable from a hot/cold pack. (Refer to the PT Modalities
Billing and Payment Article for specific billing instructions).
CPT 97012 - Mechanical Traction Therapy
Mechanical traction therapy is limited to the cervical or lumbar spine with
the expectation of relieving pain in or originating from those areas.
Specific indication for the use of mechanical traction include cervical
and/or lumbar radiculopathy and back disorders such as disc herniation,
lumbago, and sciatica.
Equipment and tables utilizing roller systems are not considered as true
mechanical traction. Services using this type of equipment should not be
billed as CPT 97012 (or any other CPT code) and are non-covered for
payment.
o Vertebral axial decompression (VAX-D) is performed for symptomatic relief
of pain associated with lumbar disk problems. The treatment combines pelvic
and/or cervical traction connected to a special table that permits the
traction application. There is insufficient scientific data to support the
benefits of this technique. Therefore, VAX-D is considered non-covered.
Supervised mechanical traction in the clinic should not be billed for
greater than 4 visits to determine the efficacy of traction and to instruct
the patient and/or caregiver in the use of a home traction unit, if
traction is providing benefit. Exceptions to the four visit limit may
RARELY be considered on an exceptional basis for a total of 12 sessions IF the
additional supervised sessions are provided on the specific order of a
physician AND clinical documentation is submitted to verify both that the
use of a home unit is medically unacceptable and that the continued use of
the traction is contributing to gains under the plan of care. This modality
is typically used in conjunction with therapeutic procedures; it is not
covered as an isolated treatment except for the four training and efficacy
sessions.
CPT 97016 - Vasopneumatic Devices
Specific indications for the use of vasopneumatic devices include:
o reduction of edema after acute injury;
o lymphedema of an extremity;
Vasopneumatic therapy sessions will be considered medically necessary up to
a total of 4 visits for the purpose of educating the patient and/or
caregiver in the use of lymphedema pump in the home or residential
facility. After four sessions the use of the lymphedema pump will not be
considered a skilled service and will therefore not be covered; the
sessions will not be considered medically necessary even though the therapy
itself is still indicated. The use of vasopneumatic devices as a billable
treatment in the clinic would not be covered as a temporary treatment while
awaiting receipt of ordered fitted compression garments.
Vasopneumatic therapy sessions will be considered medically necessary up to
a total of 6 visits for the purpose of reducing edema after an acute
injury, including surgery. It is expected that the edema will resolve
sufficiently in that time period to allow it to be further managed by other
means. Exceptions to the 4 or 6 visit limit may RARELY be considered on an
exceptional basis IF the additional visits are provided on the specific
order of a physician AND clinical documentation is submitted to justify
that use.
CPT 97018 – Paraffin Bath
Paraffin bath is primarily used for pain relief in chronic joint problems
of the wrists, hands, or feet. Specific indications for the use of paraffin
bath include:
o contracture as result of rheumatoid arthritis;
o contracture as result of scleroderma;
o acute synovitis;
o post-traumatic conditions;
o hypertrophic scarring;
o degenerative joint disease;
o osteoarthritis;
o post-surgical conditions or tendon repairs;
o status post sprains or strains.
No greater than 4 visits should be billed to educate patient and/or
caregiver in home use and to evaluate effectiveness. Exceptions to the four
visit limit may RARELY be considered on an exceptional basis IF the
additional supervised sessions are provided on the specific order of a physician
AND clinical documentation is submitted to verify both that the use of a
home unit is medically unacceptable and that the continued use of the
traction is contributing to gains under the plan of care.
CPT 97020 - Microwave
The efficacy of this intervention has not been established. This
intervention is considered Investigational and is therefore not covered.
CPT 97022 - Whirlpool
CPT 97036 - Hubbard Tank
Whirlpool and Hubbard tanks are the most common forms of hydrotherapy.
Although the use of sterile whirlpool/Hubbard tank is considered medically
necessary when used as part of a plan directed at facilitating the healing
of an open wound or burn, the purpose of the immersion is to perform
non-selective debridement. When used for this purpose these are not
considered adjunctive modalities; their use in the presence of open wounds
is discussed in Riverbend's Wound Care policy.
Whirlpool use is considered medically necessary when used to enhance the
patient’s ability to perform therapeutic exercise. As the benefit of this
modality is expected to plateau after 10 to 12 visits, no greater than 12
visits for whirlpool will be covered for the above purpose. Exceptions to
the 12 visit limit may RARELY be considered on an exceptional basis IF the
additional visits are provided on the specific order of a physician AND
clinical documentation is submitted to justify that use.
Fluidotherapy is a dry whirlpool modality (CPT 97022) using finely ground
cellulose particles (crushed corncobs) in a cabinet. Heat and air are
forced through the particles, causing them to flow like a liquid around the
area being treated, providing a superficial heat. Fluidotherapy is most
often applied to the distal end of extremities.
CPT 97022 is not covered for the treatment of muscle spasms since there are
other modalities which are more effective; this does not preclude its use
as an adjunct to therapeutic interventions for other reasons (e.g.
contractures). CPT 97036 is not covered except in the settings of wound
care and/or burn care.
CPT 97024 - Diathermy
The use of diathermy is considered reasonable and necessary for the
delivery of heat to deep tissues such as skeletal muscle and joints for the
reduction of pain, joint stiffness, and muscle spasms. Specific indications
for the use of diathermy include:
o osteoarthritis, rheumatoid arthritis, or traumatic arthritis;
o a strain or sprain;
o acute or chronic bursitis;
o a traumatic injury to muscle, ligament, or tendon resulting in functional
loss;
o joint dislocation or subluxation;
o treatment for a post surgical functional loss;
o adhesive capsulitis;
o joint contracture.
If no objective and/or subjective improvement noted after 6 treatments, a
change in treatment plan (alternative strategies) should be implemented or
documentation should support the need for continued use of this modality.
As with other modalities, this modality should be used in conjunction with
therapeutic procedures, not as an isolated treatment. The efficacy of this
modality should plateau at most in 12 visits; additional services beyond
this point will not be considered medically necessary. Documentation must
support the need of continued treatment with this modality for greater than
12 visits. Exceptions to the 12 visit limit may RARELY be considered on an
exceptional basis IF the additional visits are provided on the specific
order of a physician AND clinical documentation is submitted to justify
that use.
CPT 97026 - Infrared
Superficial heat treatment of this type ordinarily does not require the skills
of a qualified, licensed therapist and therefore is considered as a
non-skilled service, which is not separately reimbursible. Like hot and
cold packs, non-skilled IR therapy may be provided as a bundled and
unbilled service. In rare instances the skills, knowledge, and judgement of
a licensed therapist might be required in the giving of such treatment in a
particular case. Documentation must support this specific need for clinical
supervision and also demonstrate that a caregiver or other unskilled aide
could not be reasonably expected to oversee its administration.
If no objective and/or subjective improvement noted after 6 treatments, a
change in treatment plan (alternative strategies) should be implemented or
documentation should support the need for continued use of this modality.
The efficacy of this modality should be met in at most 12 visits;
additional services beyond this point will not be considered medically
necessary. Exceptions to the 12 visit limit may RARELY be considered on an
exceptional basis IF the additional visits are provided on the specific
order of a physician AND clinical documentation is submitted to justify
that use.
This modality should be used in conjunction with therapeutic procedures,
not as an isolated treatment. Infrared application in the absence of
associated therapeutic procedures or modalities, or used alone to reduce
discomfort, is considered not medically necessary, and therefore, is not
covered.
CPT 97028 - Ultraviolet
Treatment of this type is generally used for patients requiring the
application of a drying heat. For example, this treatment would be
considered reasonable and necessary for the treatment of severe psoriasis
where there is limited range of motion.
Superficial heat treatment of this type ordinarily requires some degree of
monitoring and supervision either by the patient or another individual, but
does not require the skills of a qualified, licensed therapist.
Documentation must support this specific need for clinical supervision and
also demonstrate that a caregiver or other unskilled aide could not be
reasonably expected to oversee its administration following a period of
appropriate instruction.
If no objective and/or subjective improvement noted after 6 treatments, a
change in treatment plan (alternative strategies) should be implemented or
documentation should support the need for continued use of this modality.
The efficacy of this modality as it applies to physical therapy should be
met in at most 12 visits; and, although the drying effects continue, by
that time the patient should be transitioned to home UV care. This modality
will not be considered medically necessary beyond 12 visits. Exceptions to
the 12 visit limit may RARELY be considered on an exceptional basis IF the
additional visits are provided on the specific order of a physician AND
clinical documentation is submitted to justify that use.
This modality should be used in conjunction with therapeutic procedures,
not as an isolated treatment. Ultraviolet application in the absence of
associated therapeutic procedures or modalities, or used alone to reduce
discomfort, is considered not medically necessary, and therefore, is not
covered.
CPT 97032 - Electrical Stimulation, constant attendance, requiring
direct, one-on-one patient contact by the provider.
G0283 - Electrical stimulation, other than wound care. G0283 would be
appropriately used for IFC or electrical stimulation units which are placed
on the patient by the provider and do not require the continued presence
and direct, one-on-one contact by the provider once set-up is completed.
<B< Electrical Functional
incorporating Training Gait - 97116>
(Note: CPT 97014 should not be used to bill Medicare. It has been replaced
by G0281-G0283. G0281 and G0282 are discussed in the Riverbend Wound Care
policy. CPT 64550 is for the initial application of a home TENS unit by the
physician and is neither a PT service nor a therapeutic modality.)
Electrical stimulation is covered for:
o Pain and/or spasm that is interfering with therapeutic interventions.
o Pain and/or spasm that is refractory to traditional acute interventions
such as heat and analgesia.
o Documented dependent peripheral edema with an accompanying reduction in
the ability to contract muscles.
o Documented reduction in the ability to contract muscles or in the
strength of the muscle contraction.
o Documented condition that requires an educational program for
self-stimulation of denervated muscles.
o Documented condition that requires muscle re-education involving a
training program, i.e., functional electrical stimulation.
Electrical stimulation and magnetic stimulation as therapy in the treatment
of urinary incontinence blur the line between adjnctive and primary therapy
and are used by multiple disciplines. They are included in this policy and
are addressed below in association with the related topic of Biofeedback
for urinary incontinence.
Utilization of these modalities may be necessary during the initial phase
of treatment, but there must be an improvement in function. These
modalities should be utilized with appropriate therapeutic procedures to
effect continued improvement. A limited number of visits without a
therapeutic procedure may be medically necessary for treatment of muscle
spasm and swelling, but this should not exceed 4 visits (G0283).
Electrical stimulation can be divided into several types. The specific type
of stimulation and the typical duration of treatment depends on the
indication:
A. Transcutaneous electrical nerve stimulation. Transcutaneous electrical
nerve stimulation (TENS) is indicated and covered for pain control. A
patient can usually be taught to use a TENS unit for pain control in 1-2
visits. Consequently, it is inappropriate for a patient to continue
treatment for pain with a TENS unit in the clinic setting. This service
does not require constant attendance and is therefore covered only as
G0283, up to a maximum of 4 visits of patient instruction. As an adjunctive
intervention (i.e. decreasing pain prior to therapeutic exercises), the
efficacy of this modality should be met in at most 12 visits. Documentation
must support the need of continued treatment with this modality for greater
than 12 visits. Exceptions to the 12 visit limit may RARELY be considered
on an exceptional basis IF the additional visits are provided on the
specific order of a physician AND clinical documentation is submitted to
justify that use.
B. Neuro-Muscular Electrical Stimulation. Neuro-Muscular Electrical
Stimulation (NMES) is used for retraining weak muscles following surgery or
injury. Coverage of NMES to treat muscle atrophy is limited to the
treatment of patients with disuse atrophy where the nerve supply to the
muscle is intact, including brain, spinal cord and peripheral nerves and
other non-neurological reasons for disuse atrophy. Examples include casting
or splinting of a limb, contracture due to scarring of soft tissue as in
burn lesions, and hip replacement surgery (until orthotic training begins).
In many instances the patient can be trained in the use of a home muscle
stimulator for retraining weak muscles in 1-2 visits. Once training is
completed, this procedure should not be billed as treatment modality in the
clinic. Treatment when provided by the therapist is covered for no more
than 12 visits when used as muscle re-training as it should be superceded
by other active interventions. Exceptions to the 12 visit limit may RARELY
be considered on an exceptional basis IF the additional visits are provided
on the specific order of a physician AND clinical documentation is
submitted to justify that use. This service does not require constant
attendance and is therefore covered only as G0283. Further, since this is
an adjunctive intervention, it should only be provided in combination with
one or more therapeutic procedures other than possibly during the first 3
or 4 visits.
C. Interferential current. Interferential current/medium current (IFC)
units use a frequency that allows the current to go deeper into the tissue.
IFC is used to control swelling and pain. If no objective and/or subjective
improvement in swelling and/or pain is noted after 6 visits, a change in
treatment plan (alternative strategies) should be implemented or
documentation should support the need for continued use of this modality.
For swelling and pain control, the efficacy of this modality should be met
in at most 10-12 visits. Documentation must support the need for continued
treatment with this modality for greater than 12 visits. A medical need for
constant attendance must be documented if this service is provided as
97032.
D. Functional Electrical Stimulation. The type of NMES used to enhance the
ability to walk of SCI (Spinal Cord Injury) patients is referred to as
functional electrical stimulation (FES). These devices are surface units
that use electrical impulses to activate paralyzed or weak muscles in
precise sequence. Coverage for the use of NMES/FES is limited to SCI
patients, for walking, who have completed a training program, which
consists of at least 32 physical therapy sessions with the device over a
period of 3 months. Weekly sessions must be attended. Physical therapy
sessions are only covered in the inpatient hospital, outpatient hospital,
comprehensive outpatient rehabilitation facilities, and outpatient
rehabilitation facilities. The physical therapy necessary to perform this
training must be directly performed by the physical therapist as part of a
one-on-one training program. This service cannot be done unattended, and is
only covered as part of a gait training program, with which it is
considered bundled (CPT 97116, gait training).
Coverage is limited to patients with paraplegia of both lower limbs (ICD-9
344.1) AND is limited to SCI patients with all of the following
characteristics:
o persons with intact lower motor units (L1 and below) (both muscle and
peripheral nerve);
o persons with muscle and joint stability for weight bearing at upper and
lower extremities that can demonstrate balance and control to maintain an
upright support posture independently;
o persons that demonstrate brisk muscle contraction to NMES and have
sensory perception of electrical stimulation sufficient for muscle
contraction;
o persons that possess high motivation, commitment and cognitive ability to
use such devices for walking;
o persons that can transfer independently and can demonstrate standing
independently for at least 3 minutes;
o persons that can demonstrate hand and finger function to manipulate
controls;
o persons with at least 6-month post recovery spinal cord injury and
restorative surgery;
o persons without hip and knee degenerative disease and no history of long
bone fracture secondary to osteoporosis; and
o persons who have demonstrated a willingness to use the device long-term.
FES to enhance walking for SCI patients will not be covered for SCI
patients with any of the following:
o presence of cardiac pacemakers or cardiac defibulators;
o severe scoliosis or severe osteoporosis;
o irreversible contracture;
o autonomic dysreflexia; or
o skin disease or cancer at area of stimulation.
Non-covered indications of electrical stimulation modalities include:
o Electrical stimulation used in the treatment of facial nerve paralysis,
commonly known as Bell’s Palsy is considered investigational.
o Electrical nerve stimulation used to treat motor function disorders such
as multiple sclerosis is considered investigational.
o Electrical stimulation is not reasonable and necessary for the treatment
of cerebral vascular accidents or strokes when it is determined there is no
potential for restoration of function.
CPT 97033 - Iontophoresis
Iontophoresis is a process in which electrically charged molecules or atoms
are driven into tissue with an electrical field. Voltage provides the
driving force.
The application of iontophoresis is considered medically necessary for the
topical delivery of medications into a specific area of the body for the
following conditions only:
o documented tendonitis or calcific tendonitis;
o documented bursitis;
o documented adhesive capsulitis.
If no objective and/or subjective improvement noted after 6 treatments, a
change in treatment plan (alternative strategies) should be implemented or
documentation should support the need for continued use of this modality.
The efficacy of this modality should plateau at most in 12 visits;
additional services beyond this point will not be considered medically
necessary. Exceptions to the 12 visit limit may RARELY be considered on an
exceptional basis IF the additional visits are provided on the specific
order of a physician AND clinical documentation is submitted to justify
that use. This modality will only be considered medically necessary in
conjunction with one or more therapeutic procedures during the same
session. This is a constant attendance code requiring direct, one-on-one
patient contact by the provider.
CPT 97034 - Contrast Baths
Contrast baths are a form of therapeutic heat and cold applied to distal
extremities in an alternating pattern. The effectiveness of contrast baths
is thought to be due to reflex hyperemia produced by the alternating
exposure to heat and cold. The use of contrast baths is considered
medically necessary to desensitize patients to pain.
The use of contrast baths is considered medically necessary for the
following conditions only:
o documented rheumatoid arthritis or other inflammatory arthritis;
o documented reflex sympathetic dystrophy; or
o documented sprain or strain resulting from an acute injury.
Hot and cold baths ordinarily do not require the skills of a licensed
therapist. However, it could be considered reasonable and necessary for
several visits to instruct the patient and/or caregivers in the performance
of this modality and to assess the patient’s response to the modality. This
service will be covered for up to 4 sessions in that instance.
Contrast baths may also be beneficial as an adjuctive therapy associated
with other theapeutic procedures. In rare instances the skills, knowledge,
and judgement of a licensed therapist might be required in the giving of
such treatment in a particular case. Documentation must support this
specific need for clinical supervision and also demonstrate that a
caregiver or other unskilled aide could not be reasonably expected to
oversee its administration. If the contrast baths are being provided as an
adjunct to a therapeutic procedure, the efficacy of this modality should be
met in at most 12 visits. Exceptions to the 12 visit limit may RARELY be
considered on an exceptional basis IF the additional visits are provided on
the specific order of a physician AND clinical documentation is submitted
to justify that use. If no objective and/or subjective improvement is noted
after 6 treatments, a change in treatment plan (alternative strategies)
should be implemented or documentation should support the need for
continued use of this modality.
This modality should be used in conjunction with therapeutic procedures,
not as an isolated treatment. Contrast baths in the absence of associated
therapeutic procedures or modalities, or used alone to reduce discomfort,
is considered not medically necessary, and therefore, is not covered beyond
1-4 visits for caregiver instruction.
This CPT code should not be billed when the services provided are hot and
cold packs. This is a constant attendance code requiring direct, one-on-one
patient contact by the provider.
CPT 97035 - Ultrasound
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 may receive
as much as 30% greater dosage of ultrasound than tissue not adjacent to
bone. 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 tissue may receive
a more intense irradiation, ultrasound is an ideal modality for increasing
mobility in those tissues with restricted range of motion. For the purposes
of this policy, "Ultrasound" (CPT 97035) shall be used to refer
to ultrasound, ultrasound with electrical stimulation, and phonophoresis.
The use 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 for increased flexibility of muscle, tendons, and
ligaments. Specific indications for the use of ultrasound application
include but are not limited to:
o documented tightened structures limiting joint motion that require an
increase in extensibility;
o documented symptomatic soft tissue calcification;
o documented neuromas.
Ultrasound application is not considered reasonable and necessary for the
treatment of asthma, bronchitis, or any other pulmonary condition.
Ultrasound use for conditions not listed in the Covered ICD9 Codes section
of this policy will be considered not reasonable and necessary without
additional clinical documentation. Ultrasound use in wound care is
discussed in the Riverbend Wound Care policy.
If no objective and/or subjective improvement noted after 6 treatments, a
change in treatment plan (alternative strategies) should be implemented or
documentation should support the need for continued use of this modality.
The efficacy of this modality should plateau at most in 12 visits;
additional services beyond this point will not be considered medically
necessary. Exceptions to the 12 visit limit may RARELY be considered on an
exceptional basis IF the additional visits are provided on the specific
order of a physician AND clinical documentation is submitted to justify
that use. This modality will only be considered medically necessary in
conjunction with one or more therapeutic procedures during the same
session. This is a constant attendance code requiring direct, one-on-one
patient contact by the provider.
CPT 97039 - Unlisted modality
At this point in time Riverbend has not identified any non-investigational
modalities that are appropriately reported with this code. The use of
modalities not discussed in this policy (i.e. "unlisted
modalities") will therefore not be considered to be medically
necessary and will not be covered.
CPT 97124 - Massage
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.
Therefore, massage performed with devices or electrical equipment is
non-covered.
Therapeutic massage includes effleurage, petrissage, and/or tapotement
(stroking, compression, percussion) and may be considered reasonable and
necessary as adjunctive treatment to another therapeutic procedure on the
same day, which is designed to restore muscle function, reduce edema,
improve joint motion, or for relief of muscle spasm.
If no objective and/or subjective improvement noted after 6 treatments, a
change in treatment plan (alternative strategies) should be implemented or
documentation should support the need for continued use of this modality.
The efficacy of this modality should plateau at most in 12 visits;
additional services beyond this point will not be considered medically
necessary. Exceptions to the 12 visit limit may RARELY be considered on an
exceptional basis IF the additional visits are provided on the specific
order of a physician AND clinical documentation is submitted to justify
that use. This modality will only be considered medically necessary in
conjunction with one or more therapeutic procedures during the same
session, and only one unit of service (up to 22 minutes) of massage will be
considered medically necessary on a single day. This is a constant
attendance code requiring direct, one-on-one patient contact by the
provider.
CPT 90901, 90911 - Biofeedback
Biofeedback is not covered for treatment of ordinary muscle tension states
or for psychosomatic conditions (90901). Biofeedback may occasionally be
covered as part of a pain management program when provided by appropriately
trained individuals. Since the purpose is to instruct the patient in the
application of the biofeedback techniques, no more than 4 visits will be
covered for this purpose. Other uses of biofeedback are not considered
medically necessary. Exceptions to the 4 visit limit and/or biofeedback for
other indications may RARELY be considered on an exceptional basis IF the
additional visits are provided on the specific order of a physician AND
clinical documentation is submitted to justify that use. Home use of
biofeedback therapy is not covered.
Biofeedback (90911) is covered for the treatment of stress and/or urge
incontinence in cognitively intact patients, who have failed a documented
trial of pelvic muscle exercise (PME) training. Biofeedback-assisted PME
incorporates the use of an electronic or mechanical device to relay visual
and/or auditory evidence of pelvic floor muscle tone, in order to improve
awareness of pelvic floor musculature and to assist patients in the
performance of PME.
Biofeedback therapy has proven successful for urinary incontinence when the
following exist:
o The patient is capable of participation in the treatment plan (i.e., at
least moderate cognition is required);
o The patient is motivated to actively participate in the treatment plan,
including being responsive to the care requirements (i.e., practice and
follow-through by self or caregiver);
o The patient’s condition is appropriately treated with biofeedback (i.e.,
pathology does not exist preventing the success of treatment).
Note: Non-implantable pelvic floor electrical stimulation is covered for
the treatment of stress and/or urge incontinence in cognitively intact
patients who have failed a documented trial of pelvic muscle exercise (PME)
training. A failed trial of PME training is defined as no clinically
significant improvement in urinary continence after completing 4 weeks of
an ordered plan of pelvic muscle exercises designed to increase
periurethral muscle strength. Magnetic pelvic floor stimulation is
considered experimental and is not covered.
Limitations
Physical therapy is not covered when the documentation fails to support
that the functional ability or medical condition was impaired to the degree
that it required the skills of a therapist. Physical therapy is not covered
when the documentation indicates the patient has not reached the therapy
goals and is not making significant improvement or progress, and/or is
unable to participate and/or benefit from skilled intervention or refused
to participate.
Physical therapy is not covered when the documentation indicates that a
patient has attained the therapy goals or has reached the point where no
further significant practical improvement can be expected. The skills of
the Physical Therapist are not required to maintain function.
Physical therapy is not covered when a patient suffers a temporary loss or
reduction of function and could reasonably be expected to improve
spontaneously without the services of the Physical Therapist.
Physical therapy services which are duplicative of other concurrent
rehabilitation services are not covered.
Physical therapy modalities are not covered when the underlying physical
therapy intervention would not be covered in accordance with the above
limitations.
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Coverage
Topic
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Physical,
Occupational, and Speech Therapy
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