RETIRED Local Coverage Determination (LCD)

Therapy and Rehabilitation Services (PT, OT)

L35036

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Proposed LCD
Proposed LCDs are works in progress that are available on the Medicare Coverage Database site for public review. Proposed LCDs are not necessarily a reflection of the current policies or practices of the contractor.
Retired

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L35036
Original ICD-9 LCD ID
Not Applicable
LCD Title
Therapy and Rehabilitation Services (PT, OT)
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL35036
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 03/09/2022
Revision Ending Date
03/01/2023
Retirement Date
03/01/2023
Notice Period Start Date
02/19/2016
Notice Period End Date
04/06/2016
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Current Dental Terminology © 2023 American Dental Association. All rights reserved.

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Issue

Issue Description

Novitas received an inquiry requesting that the language “the frequency and duration of the particular group setting” located under documenting group therapeutic procedures be removed to clarify that frequency and duration is not required for each group therapy setting. Upon review it was determined that the Internet-Only-Manual (IOM) 100-02, Chapter 15, Section 230(A) does not support any specific documentation guidelines for particular group therapy settings. Therefore, the language ‘frequency and duration of the particular group setting” has been removed from the ‘Group Therapeutic Procedures’ section.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

This LCD supplements but does not replace, modify, or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for therapy and rehabilitation services. Federal statute and subsequent Medicare regulations regarding provision and payment for medical services are lengthy. They are not repeated in this LCD. Neither Medicare payment policy rules nor this LCD replace, modify, or supersede applicable state statutes regarding medical practice or other health practice professions acts, definitions and/or scopes of practice. All providers who report services for Medicare payment must fully understand and follow all existing laws, regulations and rules for Medicare payment for therapy and rehabilitation services and must properly submit only valid claims for them. Please review and understand them and apply the medical necessity provisions in the policy within the context of the manual rules. Relevant CMS manual instructions and policies may be found in the following Internet-Only Manuals (IOMs) published on the CMS Web site:

IOM Citations:

  • CMS IOM Publication 100-02, Medicare Benefit Policy Manual,
    • Chapter 8, Section 30.2 Skilled Nursing and Skilled Rehabilitation Services and Section 30.4.1 Skilled Physical Therapy
    • Chapter 12, Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage
    • Chapter 15, Section 220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology
  • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, 
    • Chapter 1, Part 2, Section 150.5 Diathermy Treatment, Section 150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders, Section 160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation, Section 160.12 Neuromuscular Electrical Stimulator (NMES), Section 160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy), Section 160.16 Vertebral Axial Decompression (VAX-D) and Part 4, Section 230.8 Non-Implantable Pelvic Floor Electrical Stimulator, Section 250.1 Treatment of Psoriasis, Section 270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds, and Section 270.6 Infrared Therapy Devices
  • CMS IOM Publication 100-04, Medicare Claims Processing Manual,
    • Chapter 5, Section 10 Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services – General and Section 20 HCPCS Coding Requirement
  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment may be made for items or services which are not medically reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1862(a)(6) states that no payment shall be made for personal comfort items.
  • Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes screening and routine physical checkups.

Federal Register References:

  • 42 CFR, Section 409.32 Criteria for skilled services and the need for skilled services.
  • 42 CFR, Section 484.4 Personnel qualifications.
  • 42 CFR, Section 485.713 Condition of participation: Physical therapy services.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

History/Background and/or General Information

This LCD provides guidelines for many physical medicine and rehabilitation services. However, this LCD does not address all services. Please refer to the related LCDs located at the bottom of this policy for services not addressed in this policy.

DEFINITIONS

(Note: For a complete list of definitions that are applicable to this LCD, refer to IOM, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220A)

Covered Indications

GENERAL PHYSICAL MEDICINE & REHABILITATION (PM&R) GUIDELINES

This LCD applies to therapy services and canalith repositioning therapy. Per CMS definitions, therapy services include these services with a few exceptions. Please refer to the documents found at https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html for the complete listing of services that are “always” considered therapy services and those that are “sometimes” considered therapy services for coverage, requirement for plan of care, and coding purposes.

Please refer to the CMS IOM publications and the Federal Register citations listed at the beginning of this policy for complete coverage information.

Reasonable and necessary requirements of therapy services can be found in CMS publication IOM 100-02, Chapter 15, Section 220.2(B). 

Medicare covers therapy services personally performed only by one of the following:

  • Licensed therapy professionals: licensed physical therapists and occupational therapists.
  • Licensed PTA with appropriate supervision by a licensed physical therapist. Please refer to CMS Publication 100-02, Chapter 15, Section 230.5(C) for information regarding therapy services provided by licensed physical therapy assistants (PTAs).
  • Licensed occupational therapy assistants (OTAs) with appropriate supervision by a licensed occupational therapist. Please refer to CMS Publication 100-02, Chapter 15, Section 230.2(C) for information regarding therapy services provided by OTAs.
  • Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
  • Doctor of Optometry (OD) and Doctor of Podiatric Medicine (DPM) when performing services within their licenses’, scope of practice and their training and competency.
  • Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNSs) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
  • “Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met. Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed. Please note that unless these therapy services are performed by a “qualified” person, the services are not covered and must not be reported for Medicare payment.

Intervention with PM&R modalities and procedures is indicated when:

  • an assessment by a physician, NPP or therapist supports utilization of the intervention,
  • there is documentation of objective physical and functional limitations (signs and symptoms), and
  • the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time. 

Other specific requirements include the following:

  • If canalith repositioning is performed by therapy personnel under a therapy plan of care, Medicare expects a physical therapist to perform the service.

A written plan of care must be established by the physician, NPP, or therapist providing the services before the services are begun. Refer to CMS IOM Publication 100-02, Chapter 15, Section 220.1.3 for information regarding the therapy plan of care.

For all PM&R modalities and therapeutic procedures on a given day, it is usually not medically necessary to have more than one treatment session per discipline. Treatment times per session vary based upon the patient’s medical needs and progress toward established goals. Treatment times per session typically will not exceed 45–60 minutes. Additional time is sometimes required for more complex or slow-to-respond patients. However, documentation of the exceptional circumstances must be maintained in the patient’s medical record and be made available upon request. 

REHABILITATIVE THERAPY

The cornerstones of rehabilitative therapy are mobilization, education, and therapeutic exercise. The goal of rehabilitative medicine is discernible, functional progress toward the restoration or maximization of impaired neuromuscular and musculoskeletal function. To that end, the dynamic components of therapy, mobilization, and patient education should predominate. Passive modalities should be used in the "warm-up" phase of the patient encounter as preparation for or as an adjunct to therapeutic procedures, and in the "cool-down" phase for reduction of pain, swelling and other post-treatment syndromes. Though passive modalities may predominate in the earlier phases of rehabilitation where the patient's ability to participate in therapeutic exercise is restricted, Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care. Further, Medicare expects the patient's record to clearly reflect medical necessity for passive modalities, especially those that exceed 25 percent of the cumulative service hours of rehabilitative therapy provided for any beneficiary under a plan of care.

In more refractory cases, the practitioner will support the need for continued care with documentation that clearly outlines the factors that require continued skilled care. The contractor recognizes variability in strength, recovery time and the ability to be educated, and allows for a recertification for additional therapy, as long as adequate medical documentation by the supervising physician or therapist is recorded in the medical record and the patient continues to require the services of a skilled caregiver.

In all cases, whether the duration and intensity of rehabilitative services recommended or rendered are limited or extensive for passive or active services, Medicare expects the patient's medical record to clearly demonstrate medical reasonableness and necessity for all therapy services. When a service is provided beyond a patient's Medicare benefit and it is determined to be not medically necessary, it is denied by Medicare as a benefit category denial.

Therapeutic exercise and activities are essential for rehabilitation. The use of modalities as stand-alone treatment is not indicated as a sole approach to rehabilitation. Therefore, an overall course of rehabilitative treatment is expected to consist predominantly of therapeutic procedures (such as therapeutic exercises, neuromuscular re-education, gait training therapy, or therapeutic activities), with adjunctive use of modalities. Although passive modalities may play a larger role in the early stages of rehabilitation and in treating exacerbations it is expected that modalities will comprise a small portion of the total therapy service time involved during the course of rehabilitative therapy. Further, it is expected that the record will demonstrate both the patient's clinical progress and concomitant appropriate increasingly active therapeutic treatment.

MAINTENANCE THERAPY

Refer to CMS IOM Publication 100-02, Chapter 15, Section 220.2(D) for complete information regarding maintenance therapy.

A maintenance program consists of activities that preserve the patient's present level of function or prevent regression of that function.

Patients with long term, chronic conditions may occasionally need skilled input to update or revise their home maintenance program; and to assess the need for new, or changes to existing, assistive or adaptive equipment. Periodic evaluations of the patient’s condition and response to treatment may be covered when medically necessary if the judgment and skills of a qualified professional are required. Examples include:

  • Design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease.
  • Instructing the patient, family member(s) or caregiver(s) in carrying out the maintenance program.
  • Infrequent re-evaluations required to assess the patient’s condition and adjust the program.

If a maintenance program is not established until after the therapy program has been completed (and the skills of a therapist are not necessary), development of a maintenance program is not considered medically reasonable and necessary for the patient’s condition.

It is not medically reasonable and necessary for a qualified professional to perform or supervise maintenance programs that do not require the professional skills of a qualified professional. These situations include:

  • Services related to activities for the general good and welfare of patients (e.g., general exercises to promote overall fitness and flexibility).
  • Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients.
  • Range of motion and passive exercises that are not related to restoration of a specific loss of function but are useful in maintaining range of motion (for example: in paralyzed extremities).
  • Maintenance therapies after the patient has achieved therapeutic goals or for patients who do not require skilled care and should become patient or caregiver-directed.

Documentation, either with objective evidence or a clinically supportable statement of expectation, must be available that supports the necessity of the skilled services provided.

General Modality Guidelines

  • Modality codes for mechanical traction, unattended electrical stimulation, vasopneumatic device, paraffin bath therapy, whirlpool therapy, diathermy, and ultraviolet therapy, require supervision by the qualified professional.
  • Modality codes for manual electrical stimulation, contrast bath therapy, ultrasound therapy, hydrotherapy, and physical therapy treatment unlisted require direct (one-on-one) contact with the patient by the qualified professional.
  • Generally, adjunctive use of services billed with mechanical traction and paraffin bath therapy is coverable only if they enhance the therapeutic procedures. Documentation supporting the medical necessity and clinical justification for the continued use of these services must be made available to Medicare upon request.
  • Generally, only one heating modality per day of therapy is medically reasonable and necessary. Medicare would not expect to see multiple heating modalities billed routinely on the same day. Exceptions could include musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation containing clinical justification supporting the medical necessity for multiple heating modalities such as paraffin bath therapy, diathermy, and ultrasound therapy on the same day is essential.
  • Generally, only one hydrotherapy modality is coverable per day when the sole purpose is to relieve muscle spasm, inflammation or edema. Documentation must be available supporting the use of multiple modalities as contributing to the patient’s progress and restoration of function. Because some of the modalities are considered components of other modalities and procedures, they are not separately reimbursed. Please refer to the National Correct Coding Initiative.

Specific Modality Guidelines

The following clinical guidelines pertain to the specific modalities listed.

Electrical Stimulation for the Treatment of Wounds

Medicare provides limited coverage of electrical stimulation for the treatment of wounds. Please refer to the National Coverage Determination (NCD) 270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds for complete coverage details.

Electrical Stimulation for Indications Other Than Wound Care

Electrical stimulation for indications other than wound care is considered medically reasonable and necessary when performed as an integral part of the therapy plan of care.

The unattended electrical stimulation to one or more areas for indications other than wound care, as part of a therapy plan of care, may include the following types of electrical stimulation:

  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • Microamperage E-Stimulation (MENS)
  • Percutaneous Electrical Nerve Stimulation (PENS)
  • Electrogalvanic stimulation (high voltage pulsed current)
  • Functional electrical stimulation
  • Interferential current/medium current


These types of electrical stimulation may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function or that skilled care is necessary to maintain the current condition, to prevent or to slow further deterioration of the patient’s condition.

Electrical stimulation is typically used in conjunction with therapeutic exercises. It is expected this modality will be used in a clearly adjunctive role and not as a major component of the therapeutic encounter.

When electrical stimulation is used for muscle strengthening or retraining, the nerve supply to the muscle must be intact. It is not medically reasonable and necessary for completely denervated motor nerve disorders in which there is no potential for recovery or restoration of function.

For coverage guidelines of pelvic floor electrical stimulation, please see CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 230.8 for information on Non-Implantable Pelvic Floor Electrical Stimulation.

Mechanical Traction Therapy

This modality, when provided by physicians or independent physical therapists, is typically used in conjunction with therapeutic procedures, not as an isolated treatment; however, it may be used in weaning an acute patient to a self-administered home program. Equipment and tables utilizing roller systems are not considered true mechanical traction. Services using this type of equipment are non-covered.

When modality codes for mechanical traction and paraffin bath therapy are used alone (absent therapeutic procedures and not as a precursor to active treatment) and solely to promote healing, relieve muscle spasm, reduce inflammation and edema, or as analgesia, a limited number of visits (e.g., 1–2 visits) may be medically reasonable and necessary to determine the effectiveness of treatment and for patient education. It is usually not medically reasonable and necessary to continue modality-only treatment by the qualified professional.

Documentation should support the medical necessity of continued traction treatment in the clinic for greater than 12 visits. For cervical conditions, treatment beyond one month can usually be accomplished by self-administered mechanical traction in the home. The time devoted to patient education related to the use of home traction should be billed under mechanical traction.

Only 1 unit of mechanical traction is generally covered per date of service.

Vasopneumatic Device Therapy

The use of vasopneumatic devices may be considered medically reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema.

Specific indications for the use of vasopneumatic devices include:

  • reduction of edema after acute injury;
  • lymphedema of an extremity; or
  • education on the use of a lymphedema pump for home use.

Note: Further treatment of lymphedema by a provider after the educational visits is generally not medically reasonable and necessary.

Education for the home use of a lymphedema pump is sometimes provided by the lymphedema pump supplier. If the supplier does not provide this education, limited therapy professional visits for such purposes are allowable. Education on the use of a lymphedema pump for home use can typically be completed in no more than three (3) visits. Medicare does not expect to be routinely billed for repeated lymphedema treatments. The use of vasopneumatic devices would not be covered as a temporary treatment while awaiting receipt of ordered compression stockings. Medicare expects that documentation in the physician’s medical record must support the necessity of repeated services.

Parafin Bath Therapy

Also known as hot wax treatment, paraffin bath therapy is primarily used for pain relief in chronic joint problems of the wrists, hands or feet. Paraffin bath treatments typically do not require the unique skills of a therapist. However, the skills, knowledge and judgment of a therapist might be required in the provision of such treatment or baths in a complicated case. Only in cases with complicated conditions where skilled services are required will paraffin be covered, and then coverage is generally limited to educating the patient/caregiver in home use. Paraffin is contraindicated for open wounds or areas with documented desensitization.

Once a trial of monitored paraffin treatment has been done in the clinic over 1-2 visits and the patient has had a favorable response, the patient can usually be taught to use a paraffin unit in 1-2 visits. Consequently, it is inappropriate for a patient to continue paraffin treatment in the clinic setting.

Only 1 unit of paraffin bath therapy is generally covered per date of service.

Whirlpool Therapy and Hydrotherapy

These modalities involve the use of agitated water to relieve muscle spasms, improve circulation or promote the healing of wounds (e.g., ulcers, exfoliative skin conditions). Whirlpool bath treatments typically do not require the unique skills of a therapist.

Physician or therapist supervision of the whirlpool modality must be medically necessary for the following indications:

  • The patient’s condition is complicated by:
    • Circulatory deficiency
    • Areas of desensitization
    • Impaired mobility or limitations in the positioning of the patient
    • Concerns about safety, if left unsupervised
  • If greater than 8 visits are needed for whirlpool treatments that require the skills of a therapist, the documentation should support the medical necessity of the continued treatment. Documentation supporting the medical necessity for additional sessions must be made available to Medicare upon request.
  • It is not medically reasonable and necessary to have more than one form of hydrotherapy during a treatment session.
  • It would not be considered medically reasonable and necessary for a patient to have whirlpool services on the same date of service as a debridement service performed on the same body part.

Fluidotherapy

Refer to the CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 150.8.

Diathermy EG Microwave

Short wave diathermy is an effective modality for heating skeletal muscle. Because heating is accomplished without physical contact between the modality and the skin, it can be used even if skin is abraded, as long as there is no significant edema. The use of diathermy is considered medically 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:

  • the patient has osteoarthritis, rheumatoid arthritis, or traumatic arthritis;
  • the patient has sustained a strain or sprain;
  • the patient has acute or chronic bursitis;
  • the patient has sustained a traumatic injury to muscle, ligament, or tendon resulting in functional loss;
  • the patient has a joint dislocation or subluxation;
  • the patient requires treatment for a post-surgical functional loss;
  • the patient has an adhesive capsulitis; or
  • the patient has a joint contracture.

Diathermy is not considered medically reasonable and necessary for the treatment of asthma, bronchitis, or any other pulmonary condition.

For information on High energy pulsed wave diathermy refer to CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 150.5 Diathermy.

Ultraviolet Therapy

Photons in the ultraviolet (UV) spectrum are more energetic than those in the visible or infrared regions. Their interaction with tissue and bacteria can produce non-thermal photochemical reactions, the effects of which provide the rationale for ultraviolet treatment. Ultraviolet light is highly bacteriocidal to motile bacteria, and it increases vascularization at the margins of the wounds.

The application of ultraviolet therapy is considered medically reasonable and necessary for the patient requiring the application of a drying heat when prescribed by the attending physician. The specific indications for this therapy are:

  • A patient having an open wound. Minimal erythema dosage must be documented and made available to Medicare upon request.
  • Severe psoriasis limiting range of motion.

Only 1 unit of ultraviolet therapy is covered per date of service.

Supportive Documentation Requirements (required at least every 10 visits) for Ultraviolet Therapy:

  • Area(s) being treated
  • Objective clinical findings/measurements to support the need for ultraviolet therapy
  • Minimal erythema dosage

Electrical Stimulation

Non-wound care electrical stimulation treatment provided in therapy is commonly unattended electrical stimulation, as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.

Manual electrical stimulation requires direct (one-on-one) patient contact by the qualified professional/auxiliary personnel. Documentation should clearly describe the type of electrical stimulation provided, as well as the medical necessity of the constant contact to justify manual electrical stimulation. Devices delivering high voltage stimulation may require one-on-one patient contact.

Types of electrical stimulation that may require constant contact include the following examples:

  • Direct motor point stimulation delivered via a probe
  • Instructing a patient in the use of a home TENS unit
    • Once a trial of TENS has been done in the clinic over 1-2 visits and the patient has had a favorable response, the 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.

Coverage for Neuromuscular Electrical Stimulator (NMES) is found in the CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 160.12.

Some patients can be trained in the use of a home muscle stimulator for retraining weak muscles. Only 1-2 visits should be necessary to complete the training. Once training is completed, this procedure should not be billed as a treatment modality in a facility.

Supportive Documentation Requirements (required at least every 10 visits) for Electrical Stimulation:

  • Type of electrical stimulation used (do not limit the description to “manual” or “attended”)
  • Area(s) being treated
  • If used for muscle weakness, objective rating of strength and functional deficits
  • If used for pain include pain rating, location of pain, effect of pain on function

Iontophoresis

Iontophoresis is the introduction into the tissues, by means of an electric current, of the ions of a chosen medication. This modality is used to reduce pain and edema caused by a local inflammatory process in soft tissue, e.g., tendonitis, bursitis.

The evidence from published, peer-reviewed literature is insufficient to conclude that the iontophoretic delivery of non-steroidal anti-inflammatory drugs (NSAIDs) or corticosteroids is superior to placebo when used for the treatment of musculoskeletal disorders. Therefore, iontophoresis will not be covered for these indications.

Iontophoresis will be allowed for treatment of intractable, disabling primary focal hyperhidrosis that has not been responsive to recognized standard therapy. In those allowable situations, the procedure is for the time putting it on or removing it or for providing instruction for use at home. Good hygiene measures, extra-strength antiperspirants (for axillary hyperhidrosis), and topical aluminum chloride should initially be tried.

Contrast Bath Therapy

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.

Hot and cold baths ordinarily do not require the skills of a therapist. However, the skills, knowledge and judgment of a therapist might be required in the provision of such treatments in a particular case, e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fracture or other complication. Documentation must indicate the presence of these complicating factors and the need for skilled care. If there are no complicating factors requiring the skills of a therapist, this modality is non-covered.

Contrast bath therapy is not covered when the services provided are hot and cold packs.

It is considered medically reasonable and necessary for contrast bath therapy to be used in conjunction with therapeutic procedures and not as an isolated treatment. Contrast bath therapy is a constant attendance code requiring direct, one-on-one patient contact by the provider.

No more than 2 visits will generally be covered to educate the patient or caregiver in home use, and to evaluate effectiveness. Documentation must support the medical necessity of continued use of contrast bath therapy for greater than 2 visits.

Supportive Documentation Requirements (required at least every 10 visits) for Contrast Bath Therapy:

  • Rationale requiring the unique skills of a therapist to apply, including the complicating factors
  • Area(s) being treated
  • Subjective findings to include pain ratings, pain location, effect on function

Ultrasound Therapy

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.

It is considered medically reasonable and necessary that ultrasound may be pulsed or continuous width; and for it to be used in conjunction with therapeutic procedures, not as an isolated treatment.

Specific indications for the use of ultrasound application include but are not limited to:

  • limited joint motion that requires an increase in extensibility
  • symptomatic soft tissue calcification
  • neuromas

Phonophoresis (the use of ultrasound to enhance the delivery of topically applied drugs) is considered ultrasound therapy. The contact medium and drugs associated with phonophoresis are considered part of the service.

If no objective 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 ultrasound. Documentation must clearly support the need for ultrasound for more than 12 visits.

Supportive Documentation Requirements (required at least every 10 visits) for Ultrasound Therapy:

  • Area(s) being treated
  • Frequency and intensity of ultrasound
  • Objective clinical findings such as measurements of range of motion and functional limitations to support the need for ultrasound
  • Subjective findings to include pain ratings, pain location, effect on function

Hubbard Tank - to one or more areas

This modality involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.

One-on-one supervision of the patient by qualified professional/auxiliary personnel is required. Hubbard tank treatments for more than 12 visits requires clear documentation supporting the medical necessity of continued use of this modality and the continued necessity for the services of a skilled therapist.

It is not medically reasonable and necessary to have more than one form of hydrotherapy during a visit (whirlpool therapy and Hubbard Tank therapy).

Supportive Documentation Requirements:

  • Rationale requiring the unique skills of a therapist to apply, including the complicating factors and area(s) being treated.

General Guidelines for Therapeutic Procedures

  • Therapeutic procedures are procedures that attempt to reduce impairment and improve function through the application of clinical skills or services.
  • Codes for therapeutic exercises, neuromuscular re-education, aquatic therapy/exercises, and therapeutic activities describe several different types of therapeutic interventions. The expected goals documented in the treatment plan, affected by the use of each of these procedures, will help define whether these procedures are medically reasonable and necessary. Therefore, since any one or a combination of more than one, of therapeutic exercises, neuromuscular re-education, aquatic therapy/exercises and therapeutic activities may be used in a treatment plan, the documentation must support each service as it relates to the specific therapeutic goal(s).

The following clinical guidelines pertain to the specific listed therapeutic procedures.

Therapeutic Exercises

Therapeutic exercise is designed to develop strength and endurance, range of motion, and flexibility and may include: active, active-assisted or passive (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening) exercises. The exercise may be medically reasonable and necessary for a loss or restriction of joint motion, strength, functional capacity or mobility that has resulted from a specific disease or injury. It is considered medically reasonable and necessary if an exercise is taught to a patient and performed by a skilled therapist for the purpose of restoring functional strength, range of motion, endurance training, and flexibility. Documentation must show objective loss of joint motion, strength or mobility (e.g., degrees of motion, strength grades, levels of assistance). This therapeutic procedure is measured in 15-minute units with therapy sessions frequently consisting of several units.

Many therapeutic exercises may require the unique skills of a therapist to evaluate the patient’s abilities, design the program, and instruct the patient or caregiver in safe completion of the special technique. However, after the teaching has been successfully completed, repetition of the exercise, and monitoring for the completion of the task, in the absence of additional skilled care, is non-covered.

Neuromuscular Reeducation

This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Feldenkrais, Bobath, BAP’s boards and desensitization techniques). The procedure may be medically reasonable and necessary for impairments that affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, hypo/hypertonicity). For example, a gym ball exercise used for the purpose of improving balance should be considered as neuromuscular reeducation.

Aquatic Therapy

For requirements on furnishing therapy services in a pool, please refer to the CMS IOM, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220C for a complete discussion on renting/leasing pool space, use of the rented/leased space, and documentation required to support these requirements.

This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be medically reasonable and necessary for a loss or restriction of joint motion, strength, mobility or function that has resulted from a specific disease or injury.

  • Documentation must show objective loss of joint motion, strength or mobility (e.g., degrees of motion, strength grades, level of assistance).
  • Aquatic therapy is only appropriate for situations where exercise is being performed in the water environment.

In addition, aquatic therapy may be considered medically reasonable and necessary when:

  • the patient cannot perform land-based exercises effectively to treat their condition without first undergoing the aquatic therapy, or
  • aquatic therapy facilitates progression to land-based exercise or increased function. Documentation must be available in the record to support medical necessity.

It is not medically reasonable and necessary to employ hydrotherapy and aquatic therapy during the same treatment session.

Note: Hydrotherapy refers to whirlpool therapy and Hubbard Tank therapy.

Gait Training Therapy

This procedure may be medically reasonable and necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.

  • This procedure is not medically reasonable and necessary if the patient does not require skilled care.
  • Repetitive walk-strengthening exercises for feeble or unstable patients or to increase endurance do not require qualified professional supervision and will be denied as not medically reasonable and necessary.
  • Generally, it would not be considered medically reasonable and necessary to perform gait training therapy in conjunction with orthotic management and training. An exception to this would be if orthotic management and training was performed on an upper extremity in conjunction with gait training.

Massage Therapy

This procedure may be medically 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.

Myofascial Release/Soft Tissue Mobilization

This procedure may be medically reasonable and necessary for the treatment of restricted motion of soft tissues involving the extremities, neck or trunk. Skilled manual techniques (active or passive) are applied to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples include:

  • Facilitation of fluid exchange
  • Restoration of movement in acutely edematous; muscles
  • Stretching of shortened connective tissue

This procedure may be medically reasonable and necessary as an adjunct to other therapeutic procedures such as therapeutic exercises neuromuscular re-education, or therapeutic activities.

Joint Mobilization

This procedure may be medically reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure. Documentation supporting the medical necessity for continued treatment must be made available to Medicare upon request.

Manipulation

This procedure may be medically reasonable and necessary as an adjunct to other therapeutic procedures such as therapeutic exercises, neuromuscular re-education, or therapeutic activities.

Manual Lymphatic Drainage/Complex Decongestive Therapy (MLD/CDT)

MLD/CDT is indicated for both primary and secondary lymphedema. Common causes include surgical removal of lymph nodes, fibrosis secondary to radiation, and traumatic injury to the lymphatic system. Both primary and secondary lymphedemas are chronic and progressive conditions which can be brought under long-term control with effective management. By maintaining control of the lymphedema, patients can:

  • restore a normal, or near-normal, shape
  • reduce the potential for complications (e.g., cellulitis, lymphangitis, deformity, injury, fibrosis, lymphangiosarcoma [rare], etc.)
  • reduce functional deficits to resume activities of daily living

MLD/CDT consists of skin care, manual lymph drainage, compression wrapping, and therapeutic exercises. Coverage of MLD/CDT would only be considered medically reasonable and necessary if all of the following conditions have been met:

  • there is a physician-documented diagnosis of lymphedema (primary or secondary)
  • the patient has documented signs or symptoms of lymphedema
  • the patient or patient caregiver has the ability to understand and comply with the continuation of the treatment regimen at home

The goal of treatment is to reduce lymphedema of an extremity by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain such reduction of the extremity after therapy is complete. This therapy involves intensive treatment to reduce the volume by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program. Ultimately the plan must be to transfer the responsibility of care from the therapist to management by the patient, patient’s family, or patient’s caregiver.

  • In moderate-severe lymphedema, daily visits may be required for the first week
  • Education should be provided to the patient or caregiver on the correct application of the compression bandage
  • The therapeutic exercise component for MLD/CDT is covered under therapeutic exercises service

Documentation must clearly support the need for continued manual therapy treatment beyond 12-18 visits. When the patient or caregiver has been instructed in the performance of specific techniques, the performance of these same techniques should not be continued in the clinic setting and counted as minutes of skilled therapy.

Massage is not covered on the same visit as a MLD/CDT service.

Group Therapeutic Procedures

Refer to CMS publication 100-02, Chapter 15, Section 230(A) for complete information on group therapy.

In the case of group therapy, Medicare expects that skilled, medically reasonable and necessary services will be provided as appropriate to each patient’s plan of care. Therefore, group therapy sessions (two or more patients) should be of sufficient length to address the needs of each of the patients in the group.

Documentation must identify the specific treatment technique(s) used in the group, how the treatment technique will restore function, and the treatment goal in the individualized (patient-specific) plan. The number of persons in the group must also be documented. These records must be made available to Medicare upon request.

Therapeutic Activities

This procedure involves using functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance.

The activities are usually directed at a loss or restriction of mobility, strength, balance or coordination. They require the professional skills of a qualified professional and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active treatment plan and directed at a specific outcome.

Cognitive Skills Development

This activity focuses on cognitive skills development to improve attention, memory and problem-solving, with direct one-on-one patient contact by the qualified professional, each 15 minutes.

Cognitive skill training should be aimed towards improving, restoring, maintaining or preventing further deterioration of specific functions which were impaired by an identified illness or injury, and expected outcomes should be reasonably attainable by the patient as specified by the plan of care. Therefore, cognitive skills training that do not require skilled services to improve, restore, maintain, or prevent deterioration would not be appropriate. Evidence-based reviews indicate that cognitive rehabilitation (and specifically memory rehabilitation) is not recommended for patients with severe cognitive dysfunction.

Cognitive skills are an important component of many tasks, and the techniques used to improve cognitive functioning are integral to the broader impairment being addressed. Cognitive therapy techniques are most often covered as components of other therapeutic procedures, and typically would not be separately reported.

Cognitive skills activities include only those that require the skills of a therapist and must be provided with direct (one-on-one) contact between the patient and the qualified professional/auxiliary personnel. These services are also reimbursable when billed by clinical psychologists; please refer to LCD, L35070, Speech-Language Pathology (SLP) Communication Disorders. Those services that a patient may engage in without a skilled therapist or qualified professional/auxiliary personnel are not covered under the Medicare benefit.

Sensory Integration

This activity focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands, with direct one-on-one contact by the qualified professional, each 15 minutes.

The patient must have the capacity to learn from instructions. Utilization of sensory integrative techniques should be infrequent for Medicare patients.

Self-care Management Training

This procedure is medically reasonable and necessary only when it requires the professional skills of a qualified professional, is designed to address specific needs of the patient and is part of an active treatment plan directed at a specific goal.

The patient or caregiver must have the capacity to learn from instructions.

Self-care management training should be used for activities of daily living (ADL) and compensatory training for ADL, safety procedures, and instructions in the use of adaptive equipment and assistive technology for use in the home environment. It would not be appropriate to report self-care management for exercise training, orthotics, gait devices, etc.

It would not be medically reasonable and necessary to report self-care management for home instruction.

Services provided concurrently by physicians, physical therapists and occupational therapists may be covered if separate and distinct goals are documented in the treatment plans, and an integrated treatment plan is maintained by the requesting physician. Documentation must relate the training to expected functional goals the patient can potentially attain.

Community/Work Reintegration Training

This training may be medically reasonable and necessary when performed in conjunction with a patient’s individual treatment plan aimed at improving, restoring, maintaining or preventing further deterioration of specific functions that were impaired by an identified illness or injury, and when expected outcomes that are attainable by the patient are specified in the plan.

This training is medically reasonable and necessary only when it requires the professional skills of a qualified professional. Generally speaking, the professional skills of a qualified professional are not required to effect improvement or restoration of function when a patient suffers a temporary loss or reduction of function that could reasonably be expected to improve as the patient gradually resumes activities normal for them. General activity programs and all activities that are primarily social or diversional in nature are not considered medically reasonable and necessary because the professional skills of a qualified professional are not required.

Wheelchair Management Training

This procedure is medically reasonable and necessary only when it requires the professional skills of a qualified professional, is designed to address specific needs of the patient and is part of an active treatment plan directed at a specific goal.

The patient or caregiver must have the capacity to learn from instructions.

Documentation of medical necessity must be available on request for an unusual frequency or duration of training sessions. Typically, up to four sessions within one month is sufficient.

Documentation for wheelchair management training used for wheelchair propulsion training must relate the training to the expected functional goals that the patient can potentially attain.

Physical Performance Test

Physical performance testing may be medically 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 capacity.

Direct one-on-one patient contact is required.

There must be written evidence documenting the problem requiring the test, the specific test performed, and a separate measurement report. This report may include torque curves and other graphic reports with interpretation.

It is not medically reasonable and necessary for the physical performance test to be performed on a routine basis (i.e., monthly or in place of a reevaluation) or to be routinely performed on all patients treated.

It is not appropriate to report this service for patient assessments/re-assessments such as range of motion (ROM) testing or manual muscle testing completed at the start of care (as this is typically part of the examination included in the initial evaluation) or as the patient progresses through the episode of treatment.

Documentation must support the need for more than 30 minutes of time for physical performance testing.

Assistive Technology Assessment

Assistive technology assessment to restore, augment or compensate for existing function or optimize functional tasks requires direct one-on-one contact with the qualified professional, each 15 minutes, and a written report.

Assistive technology assessment is intended for use on severely impaired patients requiring adaptive technology. For example, a patient with the use of only one or no limbs might require the use of high level adaptive technology.

Orthotic Management and Training, Initial Encounter

The complexity of the patient’s condition is to be documented to show the medical necessity of skilled therapy to assess, fit, and instruct in the use of the orthotic. An orthotic is a brace that includes rigid and semi-rigid components that are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Elastic stockings, garter belts, neoprene braces and similar devices do not come within the scope of the definition of a brace. HCFA Ruling 96-1 clarifies that the “orthotics” benefit is limited to leg, arm, back, and neck braces that are used independently rather than in conjunction with, or as components of, other medical or non-medical equipment.

When consideration is made for a patient to require an orthotic, the therapist targets the problems in performance of movements or tasks, or identifies a part that requires immobilization, and selects the most appropriate orthotic device, then fits the device, and trains the patient or caregiver(s) in its use and application. The goal is either to promote indicated immobilization or to assist the patient to function at a higher level by decreasing functional limitations or the risk of further functional limitations.

It would not be considered medically reasonable and necessary to perform a therapy evaluation when an assessment related to determining the specific orthotic is performed.

An orthotic may be prefabricated or custom-fabricated. A prefabricated orthotic is one that is manufactured in quantity and then modified with a specific patient in mind. A prefabricated orthotic may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific patient (i.e., custom fitted). An orthotic that is assembled from prefabricated components is considered prefabricated.

Orthotic training is not for prefabricated/commercial (i.e., off the shelf) components such as, but not limited to a lumbar roll, non-customized foam supports/wedges (e.g., heel cushions), or multi-podus boots. Such components do not require the skills of a therapist and are non-covered. Minor modifications to prefabricated orthotics do not constitute a customized orthotic.

A custom fabricated orthotic is one that is individually made for a specific patient starting with basic materials including, but not limited to, plastic, metal, leather, or cloth, from the patient’s individualized measurements. A molded-to-patient model orthotic is a particular type of custom fabricated orthotic in which an impression of the specific body part is made and the impression is then used to make a positive model. The orthotic is molded from the patient-specific model.

It is unusual to require more than 30 minutes of static orthotics training. In some cases, dynamic training may require additional time.

Documentation supporting the medical necessity for additional time must be made available to Medicare upon request.

Generally, it would not be medically reasonable and necessary to perform gait training at the same time as orthotic management and training. An exception to this would be if orthotic management training was performed on an upper extremity at the same time that gait training was also performed.

The Medicare coverage for orthotics includes the following items.

  • Assessment of the patient regarding the orthotic
  • Measurement or fitting
  • Supplies to fabricate or modify the orthotic
  • Time associated with making the orthotic

Orthotic training may include teaching the patient regarding a wearing schedule, placing and removing the orthosis, skin care and performing tasks while wearing the device. It would not be appropriate to include the time spent assessing, measuring or fitting, fabricating or modifying, or making the orthotic in the time spent providing orthotic training. Only the time spent actually training the patient should be included in the orthotic training service.

The documentation for orthotic management and training must support the need for skilled qualified professional/auxiliary personnel to train the patient in the use and care of the orthotic. When the management of the orthotic can be turned over to the patient, the caregiver or nursing staff, the services of the therapist will no longer be covered.

An orthotic provided for positioning or increasing range of motion in a non-functional extremity must include documentation that the unique skills of a therapist are required to fit and manage the orthotic and that the orthotic is medically reasonable and necessary for the patient’s condition.

For uncomplicated conditions, the following services would not be considered medically reasonable and necessary as they would not require the unique skills of a therapist.

  • Issuing off-the-shelf splints for foot drop or wrist drop
  • Issuing off-the-shelf foot or elbow cradles for routine pressure relief (these are not considered orthotics)
  • Issuing “carrots” (i.e., cylindrical, cone-shaped forms) or towel rolls for hand contractures for hygiene purposes
  • Bed positioning (e.g., pillows, wedges, rolls, foot cradles to relieve potential pressure areas)

With chronic conditions, repetitive range of motion prior to placing an orthotic/positioner to maintain the range of motion may be considered medically reasonable and necessary when all criteria for maintenance programs are met.

Ongoing therapy visits, to increase length of time an orthotic is worn, are generally not medically reasonable and necessary when patient problems related to the orthotic have not been observed.

Ongoing visits by the qualified professional/auxiliary personnel to apply the device would be considered monitoring. Once the initial fit is established, any further visits should be used for specific documented problems and modifications that require skilled therapy. It is medically reasonable and necessary to require 1-3 visits to fit and educate the patient or caregiver. The medical necessity of any further visits must be supported by documentation in the medical record.

It is not appropriate to report orthotic training for measurements taken to obtain custom fitted burn or pressure garments. These garments do not fit the definition of an orthotic.

Supportive Documentation Requirements for orthotic management and training:

  • A description of the patient’s condition (including applicable impairments and functional limitations) that necessitates an orthotic
  • Any complicating factors
  • The specific orthotic provided and the date issued
  • A description of the skilled training provided
  • Response of the patient to the orthotic

Prosthetic Training, Initial Prosthetic Encounter

The medical record should document the distinct goal(s) and service(s) rendered when prosthetic training for a lower extremity is performed during the same treatment session as gait training or self-care/home-management training.

It is unusual to require more than 30 minutes of prosthetic training per day. Documentation supporting the medical necessity for additional time must be made available to Medicare upon request.

Orthotic/Prosthetic Management, and/or Training, Subsequent Orthotics

These subsequent assessments may be medically reasonable and necessary when a device is newly issued or there is a modification or reissue of the device.

These assessments may be medically reasonable and necessary when patients experience loss of function directly related to the orthotic or prosthetic device (e.g., pain, skin breakdown or falls).

It is unusual to require more than 30 minutes of checkout for orthotic/prosthetic use for an established patient. Documentation supporting the medical necessity for additional time must be made available to Medicare upon request.

Limitations 

The following are considered not medically reasonable and necessary:

  1. PT and OT evaluation or re-evaluation claims submitted with an evaluation and management code performed on the same day.

  2. Services not performed by or under the appropriate supervision of the therapist.

  3. Services performed by people who are not employees of, or supervised by, the therapist.

  4. Services not furnished in the therapist’s office or in the patient’s home.

  5. Ultrasound application for the treatment of:

    • asthma, bronchitis, or any other pulmonary condition;
    • conditions for which the ultrasound can be applied by the patient without the need for a therapist or other professional to administer, or for extended period of time (e.g., devices such as PainShield MD); wounds.

  6. Electrical stimulation when it is the only intervention utilized purely for strengthening of a muscle with at least Fair graded strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activities.

  7. Reporting an electrical stimulation service for constant attendance while providing an electrical stimulation modality that is typically considered supervised (such as electrical stimulation for indications other than wound care) to a patient requiring constant attendance for safety reasons due to cognitive deficits. This type of monitoring may be done by non-skilled personnel.

  8. Dry hydrotherapy massage (also known as aqua-massage, hydro-massage, or water massage).

  9. Diathermy/Microwave services.

  10. Manual Lymphatic Drainage/Complex Decongestive Therapy (MLD/CDT) for:
    • conditions reversible by exercise or elevation of the affected area;
    • dependent edema related to congestive heart failure or other cardiomyopathies;
    • patients who do not have the physical and cognitive abilities, or support systems, to accomplish self-management in a reasonable time;
    • continuing treatment for a patient non-compliant with a program for self-management.
  1. The following for group therapy:

    • Routine (i.e., supportive) groups that are part of a maintenance program, nursing rehabilitation program, or recreational therapy program
    • Groups using biofeedback for relaxation
    • Viewing videotapes; listening to audiotapes

  2. Supervision of a previously taught exercise program or supervising patients who are exercising independently is not considered a skilled service for group therapy or any other therapeutic procedure. Supervision of patients exercising on machines or exercise equipment, in the absence of the delivery of skilled care, is not considered a skilled service for group therapy or any other therapeutic procedure.

  3. Services that are related solely to specific employment opportunities, work skills or work settings for the diagnosis and treatment of an illness or injury are excluded from coverage by Section 1862(a)(1) of the Social Security Act.

    • The services of work hardening and work hardening add-on are related solely to specific work skills and are not considered medically reasonable and necessary for the diagnosis or treatment of an illness or injury.


For frequency limitations, please refer to the Utilization Guidelines section below.

Notice: Services performed for any given diagnosis must meet all of the indications and limitations stated in this LCD, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.

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Proposed Process Information

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Coding Information

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CPT/HCPCS Codes

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ICD-10-CM Codes that DO NOT Support Medical Necessity

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Please refer to the related Local Coverage Article: Billing and Coding: Therapy and Rehabilitation Services (PT, OT), A57703, for all coding information.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The medical record documentation must support the medical necessity of the services as stated in this policy. Note: Please refer to the various therapy procedures in the body of the policy and to the citations listed under the CMS National Coverage section for complete information on required documentation of therapy services.
  4. Documentation should establish the variables that influence the patient's condition, especially those factors that influence the clinician's decision to provide more services than are typical for the individual's condition. Refer to the CMS IOM, Pub. 100-02, Chapter 15, Section 220.3.
  5. Documentation supporting the medical necessity for multiple heating modalities on the same date of service must be available for review and show that all were needed toward the restoration of function.
  6. For any timed services, the total number of treatment minutes must be documented in the medical record. It is recommended but not required that the time for each timed service be noted in rounded minutes to show consistency with and support the treatment provided. Total treatment time in minutes must also be recorded in the medical record. Total treatment time is comprised of the minutes for timed code treatment and untimed code treatment. Services that are not billable (e.g., rest periods) are not included in the total treatment time and are recommended to show consistency with and support the treatment provided.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Medicare covers the following number of therapy services without routinely requiring medical review of records to determine medical necessity:

  • Five (15 minutes each) timed PT services per patient per day.
  • Five (15 minutes each) timed OT services per patient per day.
  • Sixty (15 minutes each) PT services per patient per month.
  • Sixty (15 minutes each) OT services per patient per month.

Medicare expects that the patient’s medical record will clearly demonstrate medical necessity. Further, Medicare does not expect that maximum allowable services will be routinely necessary, necessary for multiple-week periods, or necessary for the entirety of the patient’s course of treatment.

Providers of PT/OT services must be aware, however, that any service reported to Medicare, even when reported at a frequency within the following stated covered guidelines, may be denied if done so in association with medical review of the patient’s record that demonstrates no medical necessity for the services. Similarly, services in addition to the above limits may be payable when done so in association with medical review of the patient’s record that demonstrates medical necessity for additional services.

Any federally established financial limitations on outpatient therapy services’ coverage and coding rules will apply.

Notice: This LCD imposes utilization guideline limitations. Despite Medicare's allowing up to these maximums, each patient’s condition and response to treatment must medically warrant the number of services reported for payment. Medicare requires the medical necessity for each service reported to be clearly demonstrated in the patient’s medical record. Medicare expects that patients will not routinely require the maximum allowable number of services.

Sources of Information


Contractor is not responsible for the continued viability of websites listed.
Novitas JL, L35044-Physical Medicine & Rehabilitative Services, Physical Therapy and Occupational Therapy
Novitas JH, L35036-Therapy Services (PT, OT, SLP) 
Contractor Medical Directors

Bibliography

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Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
03/31/2023 R15

This LCD is being retired effective for dates of service on and after 03/01/2023 as the IOM and applicable regulations will provide guidance in place of the LCD.

  • LCD Being Retired
03/09/2022 R14

LCD revised and published on 05/05/22 effective for dates of service on and after 03/09/22 to reflect changes related to an inquiry. The 'frequency and duration of the particular group setting' has been removed from the documentation requirement within the 'Group Therapeutic Procedures' section because this language is inconsistent with the IOM instructions. Minor formatting changes have been made throughout the LCD.

  • Other (Result of inquiry)
11/14/2019 R13

Please refer to Revision History #12.

  • Other (CMS Change Request 10901)
11/14/2019 R12

LCD revised and published on 11/14/2019 to completely remove the Coding Information Section from this LCD per CMS Change Request 10901. Please see the related Billing and Coding Article, A57703 for all codes and information related to coding and billing. Consistent with CR 10901 language contained in CMS manuals, NCDs, Federal Register etc. has been removed from the policy. Due to the large amount of manual language that has been removed from the policy, the policy has been reorganized. There has been no change in coverage with this revision.

  • Other (CMS Change Request 10901)
04/18/2019 R11

LCD revised and published on 04/18/2019 in response to CMS Change Request (CR) 10901 to add CMS IOM Publication 100-08, Chapter 13 to the IOM Reference section and to remove the reference and language from the body of the LCD. CMS IOM reference for Publication 100-09 pertains to coding therefore it has been removed from the LCD. References to National Correct Coding Initiative has been updated consistent with CMS CR 10868. There has been no change in content to the LCD.

  • Other (Changes in response to CMS change request)
03/29/2018 R10

LCD revised on 03/29/2018 to clarify language pertaining to rehabilitative and maintenance therapy from the CMS IOMs. Clarification added for CPT/HCPCS code G0283 under Specific Modality Guidelines. Bill Types 18x and 21x removed as they are not applicable to inpatient services claims.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Inquiry - Clarification)
01/01/2018 R9

LCD revised and published on 01/25/2018 effective for dates of service on and after 01/01/2018 to reflect the annual CPT/HCPCS code updates. For the following CPT/HCPCS codes either the short description and/or the long description was changed: 97760, 97761. Depending on which description is used in this LCD there may not be any change in how the code displays in the document. The following CPT/HCPCS codes have been deleted and therefore removed from group 1 of the LCD: 97532, 97762. The following CPT/HCPCS codes have been added to group 1 of the LCD: 97763, G0515. The text in the policy has been updated to reflect the 2018 CPT/HCPCS Updates. Per annual LCD review, the IOM Citations have been revised in the CMS National Coverage Policy section.

At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; therefore, not all the fields included on the LCD are applicable as noted in this policy.

  • Revisions Due To CPT/HCPCS Code Changes
  • Other (Annual Review)
01/01/2017 R8 LCD revised and published on 01/12/2017 effective for dates of service on and after 01/01/2017 to reflect the annual CPT/HCPCS code updates. The following CPT/HCPCS codes: 97001, 97002, 97003, and 97004, have been deleted and therefore removed from group 1 of the LCD. The table and related statement in the Utilization Guidelines section referencing the deleted codes has been removed. The following CPT/HCPCS codes: 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168, have been added to group 1 of the LCD.
  • Revisions Due To CPT/HCPCS Code Changes
04/07/2016 R7 LCD revised and published on 09/08/2016 effective for dates of service on or after 10/01/2015 to clarify documentation requirement regarding timed services.
  • Other (Inquiry and Clarification)
04/07/2016 R6 LCD revised and published on 06/09/2016 effective for dates of service on or after 04/07/2016 to clarify language regarding supervision for physical therapy assistants. Listed related CFRs: 42 CFR 410.32, 42 CFR 484.4, 42 CFR 485.713.
  • Other (Inquiry and Clarification)
04/07/2016 R5 LCD revised and published on 04/21/2016 to remove Group 2 Paragraph for CPT code 97532 and associated Group 2 diagnosis codes: F07.0, F07.89. F07.9, F09, and F48.2. Reference to L35070-Speech-Language Pathology (SLP) Services: Communication Disorders added under CPT/HCPCS code 97532.
  • Other ((Inquiry and Clarification) )
04/07/2016 R4 LCD revised and published on 04/07/2016 to clarify language regarding group therapy.
  • Other (Inquiry and Clarification )
04/07/2016 R3 LCD posted for notice on 02/19/2016 to become effective 04/07/2016.

09/17/2015 Draft LCD posted for comment.
  • Creation of Uniform LCDs With Other MAC Jurisdiction
10/01/2015 R2 LCD revised and published on 10/08/2015 to reflect CPT code 97026 as non-covered per NCD 270.6. Added link to NCD.
  • NCD Supplementation
10/01/2015 R1 LCD revised to remove references to covered ICD-10-CM codes. Reference to diagnosis to procedure code editing removed.
  • Other (Clarification)
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