Superseded Local Coverage Determination (LCD)

Outpatient Physical and Occupational Therapy Services

L34049

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Superseded
To see the currently-in-effect version of this document, go to the section.

Contractor Information

LCD Information

Document Information

LCD ID
L34049
LCD Title
Outpatient Physical and Occupational Therapy Services
Proposed LCD in Comment Period
N/A
Source Proposed LCD
N/A
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 05/27/2021
Revision Ending Date
06/01/2022
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
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CMS National Coverage Policy

Language quoted from Centers for Medicare and Medicaid Services (CMS), National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):
Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Sections 1861(g), 1861(p), 1861(s)(2) and 1862(a)(14) of Title XVIII of the Social Security Act define the services of non-physician practitioners.

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1862(a)(20) excludes payment for PT or OT services furnished incident to the physician by personnel that do not meet the qualifications that apply to therapists, except licensing.

Code of Federal Regulations
42 CFR, Sections 410.59 and 410.61 describe outpatient occupational therapy services and the plan of treatment for outpatient rehabilitation services, respectively.

42 CFR, Sections 410.60 and 410.61 describe outpatient physical therapy services and the plan of treatment for outpatient rehabilitation services, respectively.

42 CFR, Sections 410.74, 410.75, 410.76, and 419.22 define the services of non-physician practitioners.

42 CFR, Sections 424.24 and 424.27 describe therapy certification and plan requirements.

42 CFR, Sections 424.4, 482.56, 484 and 485.705 define therapy personnel qualification requirements.

42 CFR, Section 486 describes coverage for services rendered by physical therapists in independent practice.

Federal Register
Federal Register, Vol. 72, No. 227, November 27, 2007, pages 66328-66333 and 66397-66408, revises personnel qualification standards for therapy services and certification requirements.

Federal Register, July 22, 2002, Decision Memo for Neuromuscular Electrical Stimulation (NMES) for Spinal Cord Injury (CAG 00153R), at:
http://www.cms.gov/mcd/viewdecisionmemo.asp?from2=viewdecisionmemo.asp&id=55&

CMS Publications:
CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15:

    220 through 230 Coverage and documentation requirements for physical and occupational therapy services.


CMS Publication 100-03, Medicare National Coverage Decisions Manual, (multiple sections):

    provides coverage information on several specific types of therapy services. See body of LCD for individual references.


CMS Publication 100-04, Claims Processing Manual, Chapter 5:

    10.2 Financial limitation for therapy services (therapy cap).


CMS Publication 100-04, Claims Processing Manual, Chapter 5:

    20-100 HCPCS coding and therapy billing requirements.


CMS Publication 100-04, Claims Processing Manual, Chapter 20:

    1-10 Orthotics billing.


CMS, “11 Part B Billing Scenarios for PTs and OTs”, http://www.cms.hhs.gov/TherapyServices/02_billing_scenarios.asp#TopOfPage

Communication from CMS that the Contractor LCD is not required to include the Z51.89 ICD-10-CM code.

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Abstract
This Local Coverage Determination (LCD) describes the coverage limits of outpatient physical and occupational therapy services under Medicare Part B, billed to either the Medicare Part A MAC or Part B MAC when services are provided under a therapy plan of care. These limits include specific conditions under which certain physical and occupational therapy services may be considered covered by Medicare. This LCD shall not be construed to either expand or contract the limits of coverage imposed by the therapy cap as established by Medicare. This LCD shall not be construed to expand coverage to services defined as non-covered by National Coverage Determinations (NCDs).

Definitions
CLINICIAN refers to a physician, nonphysician practitioner (physician assistant, clinical nurse specialist and nurse practitioner) or a therapist (but not to an assistant, aide or any other personnel) providing a service within their scope of practice and consistent with state and local law. Clinicians make clinical judgments and are responsible for all services they are permitted to supervise. Services that require the skills of a therapist may be appropriately furnished by clinicians, that is, by or under the supervision of qualified physicians/NPPs when their scope of practice, state and local laws allow it and their personal professional training is sufficient to provide to the beneficiary skills equivalent to a therapist for that service.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, physician, or nonphysician practitioner (NPP) who is licensed or certified by the state to perform therapy services. Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law.

QUALIFIED AUXILIARY PERSONNEL means staff (auxiliary personnel) who have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP. Qualified personnel may or may not be licensed as therapists but meet all of the requirements for therapists with the exception of licensure.

THERAPIST refers to physical therapists and occupational therapists qualified according to Medicare policy.

SKILLS OF A THERAPIST are defined by the scope of practice for therapists in the state. For clinicians who are not therapists (e.g., physicians and NPPs), personal professional training should be sufficient to provide to the beneficiary skills equivalent to a therapist (OT or PT) for that service. Skills of a therapist also include therapists supervising assistants.

PROVIDER refers to a facility or agency such as a rehabilitation agency, hospital, critical access hospitals (CAH), skilled nursing facilities (SNF), comprehensive outpatient rehabilitation facilities (CORF), home health agencies, or outpatient rehabilitation facilities (ORF).

SUPPLIERS of therapy services include individual practitioners such as physicians, NPPs, physical therapists and occupational therapists who have Medicare provider numbers.

Maintenance Program (MP) means a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.

Medical Necessity
Section 1862(a)(1)(A) of the SSA states: “No Medicare payment shall be made for expenses incurred for items or services which . . . are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

Services which do not meet the requirements for covered therapy services in Medicare manuals are not payable using codes and descriptions as therapy services. For Example, services related to activities for the general good and welfare of patients, such as general exercises to promote overall fitness and flexibility, and activities to provide diversion or general motivation, do not constitute (covered) therapy services for Medicare purposes. Services related to recreational activities such as golf, tennis, running, etc., are also not covered as therapy services.

To be considered reasonable and necessary, the services must meet Medicare guidelines. The guidelines for coverage of outpatient therapies have basic requirements in common.

In the case of rehabilitative therapy, the patient’s condition has the potential to improve or is improving in response to therapy, maximum improvement is yet to be attained; and there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time.

  • Improvement is evidenced by successive objective measurements whenever possible. If an individual’s expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.
  • Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activates (CMS Publication 100.02-, Medicare benefit Policy Manual, chapter 15, section 220.2©). For example, therapy may not be covered for a fully functional patient who developed temporary weakness from a brief period of bed rest following abdominal surgery. It is reasonably expected that as discomfort reduces and the patient gradually resumes daily activities, function will return without skilled therapy intervention.


In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient’s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver, or unskilled personnel.
A therapy plan of care is developed either by the physician/NPP, or by the physical therapist who will provide the physical therapy services, or the occupational therapist who will provide the occupational therapy services, (only a physician may develop the plan of care in a CORF). The plan must be certified by a physician/NPP.
If the goal of the plan of care is to improve functioning, the documentation must establish that the patient needs the unique skills of a therapist to improve functioning.
If the goal of the plan of care is to maintain, prevent, or slow further deterioration of functional status function or prevent deterioration, the documentation must establish that the patient needs the unique skills of a therapist to maintain, prevent, or slow further deterioration of functional status

All services provided are to be specific and effective treatments for the patient’s condition according to accepted standards of medical practice; and the amount, frequency, and duration of the services must be reasonable.

The services that are provided must meet the description of skilled therapy below.

Skilled Therapy
A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, without the direct or general supervision, as applicable, of a therapist, the service cannot be regarded as a skilled therapy service even though a therapist actually furnishes the service. Similarly, the unavailability of a competent person to provide a non-skilled service, notwithstanding the importance of the service to the patient, does not make it a skilled service when a therapist furnishes the service.
Skilled therapy services may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, or to prevent or slow further deterioration of the patient’s condition.

Services that do not require the professional skills of a therapist to perform or supervise are not medically necessary. The skills of a therapist may also be furnished by an appropriately trained and experienced physician or NPP, or by an assistant (PTA, OTA) appropriately supervised by a therapist. Therefore, if a patient’s therapy can proceed safely and effectively through a home exercise program, self management program, restorative nursing program or caregiver assisted program, payment cannot be made for therapy services.
Consider the following points when determining if a service is skilled.

    • Rehabilitative therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in each state) are necessary to safely and effectively furnish a recognized therapy service, whose goal is improvement of an impairment or functional limitation.
      • The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can only be safely and effectively performed by a qualified clinician, or therapists supervising assistants.

 

    • Maintenance therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in each state) are necessary to safely and effectively furnish a recognized therapy service, whose goal is to maintain functional status or prevent or slow further deterioration in functional status.
        • If the specialized skill, knowledge, and judgement of a qualified therapist are required to establish or design a maintenance program to maintain the patient’s current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered.
        • If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered.
        • If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.
        • Such skilled care is necessary for the performance of a safe and effective maintenance program only when;
          • The therapy procedures required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or
          • The particular patient’s special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient’s current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedure.

      • Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiary’s need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver, or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgement, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.

 

    • While a beneficiary’s particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the service(s) can be carried out by non-skilled personnel.
    • If at any point in the treatment it is determined that the treatment becomes repetitive and does not require the unique skills of a therapist, the services are non-covered.
    • There may be circumstances where the patient, with or without the assistance of an aide or other caregiver, does activities planned by a clinician. Although these activities may be supportive to the patient’s treatment, if they can be done by the patient, aides or other caregivers without the active participation of qualified professional/auxiliary personnel, they are considered unskilled.
    • An individualized plan of exercise and activity for patients and their caregiver(s) may be developed by clinicians to maintain and enhance a patient’s progress during the course of skilled therapy, as well as after discharge from therapy services. Such programs are an integral part of therapy from the start of care and should be expected and modified as the patient progresses.
      • If a patient’s limited ability to comprehend instructions, follow directions, or remember skills that are necessary to achieve an increase in function, is so severe as to make functional improvement very unlikely, rehabilitative therapy is not required, and therefore, is not covered. However, limited services in these circumstances may be covered with supportive documentation, if the skills of a therapist are required to establish and teach a caregiver a safety or maintenance program.

 

      • This does not apply to the limited situations where rehabilitative therapy is reasonable and achieving meaningful goals is appropriate, even when a patient does not have the ability to comprehend instructions, follow directions or remember skills. Examples include sitting and standing balance activities that help a patient recover the ability to sit upright in a seat or wheel-chair, or safely transfer from the wheelchair to a toilet.
      • This also does not apply to those patients who have the potential to recover abilities to remember or follow directions, and treatment may be aimed at rehabilitating these abilities, such as following a traumatic brain injury.

 

  • The use of therapy equipment such as therapeutic pools or gym machines alone does not necessarily make the treatment skilled.
  • Medicare does not cover packaged or predetermined therapy services or programs, such as Back Schools or pre-operative joint classes with preset educational activities and exercises for all participants involved. Services must be individualized, medically necessary and require the unique skills of a therapist. (Packaged or predetermined therapy services do not apply to post-surgical protocols that provide ranges and guidance.)




Personnel Authorized to Provide Outpatient Therapy Services
Medicare billable therapy services may be provided by any of the following within their scope of practice and consistent with state and local law:

  • Physician;
  • Non-physician practitioner (NPP) (physician assistants, nurse practitioners, clinical nurse specialists);
  • Qualified physical and occupational therapists, speech language pathologists, and assistants working under the supervision of a qualified therapist;
  • Qualified personnel, with or without a license to practice therapy, who have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP.



The new personnel qualifications for physical therapists, physical therapist assistants, occupational therapists and occupational therapy assistants were discussed in the 2008 Physician Fee Schedule. See the Federal Register of November 27, 2007 for the full text. See also the correction notice for this rule, published in the Federal Register on January 15, 2008.

Personnel NOT Authorized to Provide Outpatient Therapy Services
Students*, aides, athletic trainers, exercise physiologists, massage therapists, recreation therapists, kinesiotherapists, low vision specialists, lymphedema specialists, Pilates instructors, rehabilitation technicians and life skills trainers are not considered qualified therapy professionals and may not bill their services under the Medicare therapy benefit, even if performed under the supervision of a qualified therapist.
* See Therapy Students section for further clarification regarding student participation in treatment.
CMS established the qualifications to assure that all personnel who provide therapy services are suitably trained in the discipline they practice. Personnel who do not meet the applicable professional standards to be considered qualified professional/personnel cannot furnish or be paid for physical or occupational therapy services.

Therapy Students
Qualified professionals may serve as clinical instructors for therapy students within their scope of practice. Physical therapist assistants and occupational therapy assistants may only serve as clinical instructors for physical therapist assistant students and occupational therapy assistant students, respectively, when performed under the direction and supervision of the licensed physical or occupational therapist (in states where licensure applies).
Services performed by a student (therapy student or therapy assistant student) are not reimbursed, even if provided under “line of sight” supervision of the therapist. However, the services of a qualified professional are covered, even when a student is participating in the care.
To be covered when the student is participating, the qualified professional must be present in the room and must:

  • Direct the service, making the skilled judgment and assessment, and assume responsibility for the treatment;
  • Not be engaged in treating another patient or doing other tasks at the same time (such as documentation); AND must
  • Sign all documentation appropriately. A student may also sign the documentation, but it is not necessary since the Part B payment is for the qualified professional’s service, not for the student’s services.



Supervision Levels
Supervision levels for outpatient therapy services depend on the setting where they are provided. Direct supervision (in the office suite) by a physician/NPP is required for therapists and qualified auxiliary personnel when therapy services are provided incident to the services of a physician/NPP. Also, direct supervision by a physical therapist (for PTAs) or occupational therapist (for OTAs) is required when assistants provide therapy services in the private practice setting or in the office of a physician/NPP. General supervision (the supervising therapist is available but not necessarily on the premises) is required by a physical therapist (for PTAs) or occupational therapist (for OTAs) when therapy services are provided in any other setting.

Private Practice Therapy Services
All therapy medical necessity, certification, documentation and coding guidelines of this LCD apply to all outpatient settings, including therapy services provided by private practitioners. In addition, in the private practice setting, all services not performed by the therapist must be performed by an assistant who is an employee of the practice and must be under direct supervision of the therapist.

To qualify as a private practice, each individual must be enrolled as a private practitioner and employed in one of the following practice types:

  • Unincorporated solo practice, partnership, or group practice;
  • Physician/NPP group or groups that are not professional corporations, if allowed by state and local law;
  • Physical or occupational therapist employed by physician/NPP group practices (PTPP, OTPP), if state and local law permits this employee relationship.


Private practice also includes therapists who are practicing therapy as employees of another supplier, of a professional corporation or other incorporated therapy practice. Private practice does not include individuals when they are working as employees of an institutional provider.
Services should be furnished in the therapist’s or group’s office or in the patient’s home. The office is defined as the location(s) where the practice is operated during the hours that the therapist engages in the practice at that location. If the services are furnished in a private practice office space, that space shall be owned, leased, or rented by the practice and used for the exclusive purpose of operating the practice.

Therapy Provided by Physicians and Physician Employees
Physical and occupational therapy services may be provided by physicians, non-physician practitioners (NPPs), or incident-to the services of physicians/NPPs when provided by physical or occupational therapists, in the office or home. All therapy medical necessity, certification, documentation, and coding guidelines of this LCD apply with one exception. When therapy services are performed incident-to a physician’s/NPP’s service, the therapist does not need a license to practice therapy, unless it is required by state law. All other physical or occupational therapist qualifications (education and training) must be met. Therapy services must be directly supervised. The services of PTAs and OTAs also may not be billed incident to a physician’s/NPP’s service. However, if a PT and PTA (or an OT and OTA) are both employed in a physician’s office, the services of the PTA, when directly supervised by the PT or the services of the OTA, when directly supervised by the OT may be billed by the physician group as PT or OT services using the PIN/NPI of the enrolled PT (or OT). (See Section 230.4 for private practice rules on billing services performed in a physician’s office.) If the PT or OT is not enrolled, Medicare shall not pay for the services of a PTA or OTA billed incident to the physician’s service, because they do not meet the qualification standards in 42CFR484.4.

Indications and Limitations of Coverage and/or Medical Necessity:

The following services are typically considered rehabilitative. This is not intended to be an exhaustive list of therapy services and does not assure coverage.

Therapy services should be provided in a manner that meets the patient’s needs. The treatment plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources. Because medical review decisions are made based on documentation in the medical record, this LCD provides recommendations intended to assist qualified professionals/auxiliary personnel in documenting to support both the medical necessity and the skilled nature of the therapy services provided. In addition, any numerical guidelines related to individual codes in this section of the LCD, are based on contractor medical review experience. These are provided to remind qualified professionals/auxiliary personnel of the importance of justifying therapy services in the documentation as the patient progresses through an episode of care. The guidelines presented under the sections “Supportive Documentation Recommendations” are not mandated, and it is not necessary to document these recommended points for each treatment session (unless otherwise specified in the LCD).
Please refer to CMS publication 100-02, Medicare Benefit Policy Manual, Chapter 15, section 220.3 for the Medicare minimal documentation requirements for therapy services.

PT evaluation  OT evaluation
The initial evaluation should document the necessity of a course of therapy through objective findings and subjective patient/caregiver self-reporting. Initial evaluations must be completed by the therapist or physician/NPP that will be providing the therapy services. Initial evaluations are completed to determine the medical necessity of initiating rehabilitative therapy or skilled instruction in maintenance activities that the patient and/or caregiver can perform at home.
Initial evaluation may be warranted when there is a change in functional ability. The evaluation should clearly describe the presenting complaint or problem for which the patient is seeking services of the physical or occupational therapist.
The evaluation process assesses, for example, the severity and impact of the current problem, the possibility of multi-site or multi-system involvement, the presence of pre-existing systemic conditions (e.g., diseases), and the stability of the condition. If the patient presents with multi-system involvement and/or multiple site involvement, all pertinent areas/conditions should be assessed at the initial evaluation (i.e., cervical pain and knee pain; low back pain and rotator cuff irritation; cervical pain and low back pain). Only one initial evaluation code should be used, and all presenting complaints and problems evaluated. If over the course of an episode of treatment, a new, unrelated diagnosis occurs, another initial evaluation may be covered.

Initial evaluations may be covered when the documentation justifies the need for a skilled therapy evaluation, even if it is determined that the patient does not require a skilled level of treatment.

  • When an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP. The goal, frequency, and duration of treatment are implied in the diagnosis and one-time service. The referral/order of a physician/NPP is the certification that the evaluation is needed and the patient is under the care of a physician. Therefore, when evaluation is the only service, a referral/order and evaluation are the only required documentation. If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient.


Screening may be more appropriate than evaluation in some circumstances. For example, a patient develops an acute lateral epicondylitis from painting. The patient seeks physician attention who subsequently recommends that the patient see an occupational therapist. By the time the patient sees the OT, she presents without any pain and has resumed all normal functional activities. Completing a screening interview of this patient should lead the therapist to determine that an OT evaluation and treatment would not be medically necessary.

  • A screening is the gathering of information to determine the need for further evaluation by the clinician. The screening process may include a review of the patient’s medical record, a patient interview and observation of the patient.
  • Routine screening is not a billable service. Although some regulations and state practice acts require screening evaluations at specific intervals (such as at admission to a nursing home, or quarterly during the patient’s stay), for Medicare payment, evaluations must meet Medicare coverage guidelines.


Initial evaluations from other therapy disciplines performed on the same beneficiary may also be covered, provided the evaluation and plan of care are not duplicative.
For initial evaluations, physical therapists and occupational therapists should use the appropriate physical therapy and/or occupational therapy evaluation code. Physicians and other qualified non-physician providers should use the evaluation and management codes for evaluations.

Consider the following points when billing for an evaluation.

  • These evaluation codes are untimed, billable as one unit.
  • Do not bill for a therapy initial evaluation for each therapy discipline on more than one date of service. If an evaluation spans more than one day, the evaluation should only be billed as one unit for the entire evaluation service (typically billed on the day that the evaluation is completed). Do not count as therapy “treatment” the additional minutes needed to complete the evaluation during the subsequent session(s).
  • Do not bill test and measurement, range of motion (ROM) or manual muscle testing (MMT) codes on the same day as the initial evaluation. The procedures performed are included in the initial evaluation codes and are not allowed by the Correct Coding Initiative (CCI) edits.
  • Do not bill therapy screenings utilizing the evaluation codes. Screenings are not billable services.
  • Evaluations for deconditioning after hospitalization where it is anticipated that prior functional abilities would spontaneously return through patient, caregiver and/or nursing activities are not considered medically necessary and are not covered.
  • Pre-operative evaluations performed routinely to ascertain the patient’s post- surgical needs and/or to explain the services that will be provided post-operatively are non-covered. The patient’s post-op experience and functional limitations are unknown prior to the surgery and will at that time require a new evaluation of the situation when medically necessary.
  • If treatment is given on the same day as the initial evaluation, the treatment is billed using the appropriate CPT codes. The documentation must clearly describe the treatment that was provided in addition to the evaluation.


Supportive Documentation Recommendations for physical therapy and occupational therapy evaluation codes
Refer to the Documentation Requirements Section of this LCD for further information.

PT reevaluation  OT reevaluation
The reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services. Reevaluation provides additional objective information not included in other documentation, such as treatment or progress notes.

Reevaluations are distinct from therapy assessments. Assessments are considered a routine aspect of intervention and are not billed separately from the intervention. For example, a patient is being seen in physical or occupational therapy for shoulder pain and limited shoulder functional range of motion due to capsular tightness. Prior to performing shoulder joint mobilizations, the therapist assesses the patient’s ROM and pain level/pattern to determine the effect of prior treatment and, if further mobilization is warranted, to determine the appropriate mobilizations. After the mobilizations are completed, the ROM is assessed again to determine the effects of the treatment just performed. The time required to assess the patient before and after the intervention is added to the minutes of the treatment intervention. Continuous assessment of the patient’s progress is a component of the ongoing therapy services, and is not payable as a reevaluation.

Consider the following points when billing for a reevaluation.

  • Indications for a reevaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care.
  • When reevaluations are done for a significant change in condition, documentation must show a significant improvement, decline or change in the patient’s diagnosis, condition or functional status that was not anticipated in the current plan of care. When a patient exhibits a demonstrable change in functional ability, a reevaluation may be necessary to revise long term goals and interventions. The plan of care may need to be revised and recertified if significant changes are made, such as a change in the long-term goals.
  • If a patient is hospitalized during the therapy interval, a reevaluation may be medically necessary if there has been a significant change in the patient’s condition which has caused a change in function, long term goals, and/or treatment plan.
  • Reevaluations may be appropriate at a planned discharge when documentations supports the medical necessity for the reevaluation service.
  • Therapy reevaluations should contain all the applicable components of an initial evaluation and must be completed by a clinician. (See the Reevaluation section of Documentation Requirements for information regarding therapy assistant participation in the reevaluation process.)
  • A reevaluation is not a routine, recurring service. Do not bill for routine reevaluations, including those done for the purpose of completing an updated plan of care, a recertification report, a progress report, or a physician progress report. Although some state regulations and practice acts require reevaluations at specific intervals, for Medicare payment, reevaluations must meet Medicare coverage guidelines.
  • These reevaluation codes are untimed, billable as one unit.
  • Do not bill for reevaluations as unlisted codes or test and measurement, ROM, MMT codes.


Supportive Documentation Recommendations for reevaluations
Refer to the Documentation Requirements Section of this LCD for further information.

MODALITIES

General Modality Guidelines

General modalities such as traction, paraffin baths, whirlpool, vasopneumatic devices, infrared, ultraviolet, and diathermy require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.
General modalities such as electrical stimulation, contrast baths, ultrasound, iontophoresis, hubbard tank, and any time a modality does not have a specific code that needs to use unlisted modality code require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes indicates the provider is performing the modality and cannot be performing another procedure at the same time. Only the actual time of the provider’s direct contact with the patient, providing services requiring the skills of a therapist, is covered for these codes.
Modalities chosen to treat the patient’s symptoms/conditions should be selected based on the most effective and efficient means of achieving the patient’s functional goals. Seldom should a patient require more than one (1) or two (2) modalities to the same body part during the therapy session. Use of more than two (2) modalities on each visit date is unusual and should be carefully justified in the documentation.
The use of modalities as stand-alone treatments is rarely therapeutic, and usually not required or indicated as the sole treatment approach to a patient’s condition. The use of exercise and activities has proven to be an essential part of a therapeutic program.
Therefore, a treatment plan should not consist solely of modalities, but should also include therapeutic procedures. (There are exceptions, including wound care or when patient care is focused on modalities because the acute patient is unable to endure therapeutic procedures.) Use of only passive modalities that exceeds 4 visits should be very well supported in the documentation.

Multiple heating modalities should not be used on the same day. Exceptions are rare and usually involve musculoskeletal pathology/injuries in which both superficial and deep structures are impaired. Documentation must support the use of multiple modalities as contributing to the patient’s progress and restoration of function. For example, it would not be medically necessary to perform both thermal ultrasound and thermal diathermy on the same area, in the same visit, as both are considered deep heat modalities.
When the symptoms that required the use of certain modalities begin to subside and function improves, the medical record should reflect the discontinuation of those modalities, so as to determine the patient’s ability to self-manage any residual symptoms. As the patient improves, the medical record should reflect a progression of the other procedures of the treatment program (therapeutic exercise, therapeutic activities, etc.). In all cases, the patient and/or caregiver should be taught aspects of self-management of his/her condition from the start of therapy.

Based on the CPT descriptors, these modalities apply to one or more areas treated (e.g., paraffin bath used for the left and right hand is billed as one unit).

Hot or cold packs therapy
Hot or cold packs (including ice massage) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a therapist.
Hot or cold pack therapy may be bundled with any therapy code. Regardless of whether code this is billed alone or in conjunction with another therapy code, this code is never paid separately. If billed alone, this code will be denied.
Supportive Documentation Recommendations for hot or cold pack therapy

  • The area(s) treated
  • The type of hot or cold application



Mechanical traction therapy
Traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas.

Specific indications for the use of mechanical traction include cervical and/or lumbar radiculopathy and back disorders such as disc herniation, lumbago, and sciatica.
This modality is typically used in conjunction with therapeutic procedures, not as an isolated treatment.
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 97012.
Only 1 unit of mechanical traction therapy is generally covered per date of service.
Equipment and tables utilizing roller systems are not considered true mechanical traction. Services using this type of equipment are non-covered.

Non-Surgical Spinal Decompression Non-surgical spinal decompression 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, non-surgical spinal decompression is not covered by Medicare (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual: Section 160.16). Examples of this type of non-covered procedure include, but are not limited to, VAX-D™, DRX-3000, DRX9000, Decompression Reduction Stabilization (DRS) System, IDD, MedX., Spina System, Accua-Spina System, SpineMED Decompression Table, Lordex Traction Unit, Triton DTS, and Z-Grav. If billed for purpose of receiving a denial, these services should be billed using an unlisted modality CPT code.

Supportive Documentation Recommendations for mechanical traction therapy

  • Type of traction and part of the body to which it is applied, etiology of symptoms requiring treatment.


Electrical stimulation (unattended)
The AMA CPT for electrical stimulation is not a Medicare recognized code. See HCPCS code for electrical stimulation (unattended).


Vasopneumatic device therapy
The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema or lymphedema.



Specific indications for the use of vasopneumatic devices include reduction of edema after acute injury or lymphedema of an extremity. Education on the use of a lymphedema pump for home use is covered when medically necessary and can typically be completed in three (3) or fewer visits once the patient has demonstrated measurable benefit in the clinic environment.
Note: Further treatment of lymphedema by a vasopneumatic device rendered by a clinician after the educational visits is generally not reasonable and necessary unless the patient presents with a condition or status requiring the skills and knowledge of a physical or occupational therapist.
The use of vasopneumatic devices is generally not covered as a temporary treatment while awaiting receipt of ordered compression stockings.
See NCD 280.6 in CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual for further coverage and use information on Pneumatic Compression Devices.

Supportive Documentation Recommendations for vasopneumatic device therapy

  • Area of the body being treated, location of edema
  • Objective edema measurements (1+, 2+ pitting, girth, etc), comparison with uninvolved side
  • Effects of edema on function Type of device used



Paraffin bath therapy
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 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.
  • Documentation needs to support more than 2 visits to educate patient and/or caregiver in home use once effectiveness has been determined.



Supportive Documentation Recommendations for paraffin bath therapy

  • Rationale for requiring the unique skills of a therapist to apply and train the patient/caregiver, including the complicating factors
  • Area of body treated



Whirlpool therapy
Whirlpool bath treatments typically do not require the unique skills of a therapist. However, therapist supervision of the whirlpool modality may be medically necessary for the following indications:

  • a condition complicated by a circulatory deficiency or areas of desensitization;
  • an open wound which is draining, has a foul odor, or necrotic tissue;
  • exfoliative skin impairments.



If greater than 8 visits are needed for whirlpools that require the skills of a therapist, the documentation should support the medical necessity of the continued treatment.
Only 1 unit of whirlpool therapy should be billed per date of service.
Dry hydrotherapy massage (also known as aquamassage, hydromassage, or water massage) is considered investigational and is non-covered.
Whirlpool should not be separately billed when provided on the same date of service as debridement for the same body part.

Fluidotherapy
Fluidotherapy is a superficial dry heat modality consisting of a whirlpool of finely divided solid particles suspended in a heated air stream, the mixture having the properties of a liquid. Use of fluidized therapy dry heat is covered as an acceptable alternative to other heat therapy modalities in the treatment of acute or sub-acute traumatic or non- traumatic musculoskeletal disorders of the extremities. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 150.8)

Supportive Documentation Recommendations for fluidotherapy

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




Diathermy eg microwave
The objective of these treatments is to cause vasodilation and relieve pain from muscle spasm. 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.
Diathermy achieves a greater rise in deep tissue temperature than microwave. As diathermy is considered a deep heat treatment, careful consideration should be given to the size, location and depth of the tissue the diathermy is intended to heat. For example, it may not be appropriate to perform diathermy treatment to the wrist or hand as most intended tissues would be considered superficial and the area is relatively small.
Diathermy may be indicated when a large area of deep tissues requires heat. It would not be reasonable and necessary to perform both thermal ultrasound and diathermy to the same region of the body in the same visit as both are considered deep heat modalities.
Pulsed wave diathermy is covered for the same conditions and to the same extent as standard diathermy. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 150.5)

Both standard and pulsed wave diathermy are contraindicated in the following settings:

  • Malignancy;
  • Sensory loss; Tuberculosis;
  • Metallic implants or foreign bodies;
  • Pregnancy;
  • Application over moist dressings; Ischemic areas or arteriosclerosis;
  • Thromboangiitis obliterans;
  • Phlebitis;
  • Cardiac pacemakers or other such implanted devices (e.g. pain pumps);
  • Contact lenses or other ocular use;
  • Metal-containing intrauterine contraceptive devices;
  • Metal in contact with skin (eg, watches, belt buckles, jewelry);
  • Use over epiphyseal areas of developing bones;
  • Active menses;




In addition, extreme care must be used with pediatric or geriatric patients.



Diathermy is not considered reasonable and necessary for the treatment of asthma, bronchitis, or any other pulmonary condition. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 240.3) Microwave is not a covered service.

Only 1 unit of diathermy is covered per date of service. If no objective and/or subjective improvement are noted after 6 treatments, a change in treatment plan (alternative strategies) should be implemented, or documentation should include the therapist’s rationale for continued diathermy. Documentation must clearly support the need for diathermy more than 12 visits.
Supportive Documentation Recommendations for Diathermy

  • Area(s) being treated
  • Objective clinical findings/measurements to support the need for a deep heat treatment
  • Subjective findings to include pain ratings, pain location, activities which increase or decrease pain, effect on function, etc.



Infrared therapy-including Anodyne

Not covered: The Centers for Medicare & Medicaid Services has determined that there is sufficient evidence to conclude the use of infrared therapy devices and any related accessories is not reasonable and necessary. The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including the symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues. See CMS Publication 100-03 Medicare National Coverage Determinations (NCD) Manual, section 270.6 and Publication 100-04, Medicare Claims Processing Manual, Chapter 5, section 20.4.

Ultraviolet therapy
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.

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

Supportive Documentation Recommendations for ultraviolet therapy

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


Electrical stimulation

Most non-wound care electrical stimulation treatment provided in therapy 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 is a constant attendance electrical stimulation modality that requires direct (one- on-one) manual patient contact by the qualified professional/auxiliary personnel. Because the use of a constant, direct contact electrical stimulation modality is less frequent, documentation should clearly describe the type of electrical stimulation provided.
Types of electrical stimulation that may require constant attendance when continuous presence by the qualified professional/auxiliary personnel is required 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.
      • Note that the application of surface (transcutaneous) neurostimulator and is an operative/postoperative code. Use of this code would seldom fall under a therapy plan of treatment.

 

    • Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES) while performing a therapeutic exercise or functional activity may be billed. Do not bill for therapeutic procedure for the same time period.
      • Use for Walking in Patients with Spinal Cord Injury (SCI) the type of NMES that is used to enhance the ability to walk of SCI patients is commonly referred to as functional electrical stimulation (FES). See the section on gait training for information on coverage for this use of NMES. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 160.12)

 

  • Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound. Do not bill for both ultrasound and electrical stimulation for the same time period.
  • If providing an electrical stimulation modality that is typically considered supervised to a patient requiring constant attendance for safety reasons due to cognitive deficits, do not bill as manual electrical stimulation. This type of monitoring may be done by non-skilled personnel.



Non-Implantable Pelvic Floor Electrical Stimulation (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8.)

  • Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature.


Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as manual electrical stimulation. Stimulation delivered via electrodes should be billed as unattended electrical stimulation.

  • The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.
  • Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary 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.
  • The patient's medical record must indicate that the patient receiving a non- implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training.


Utilization of electrical stimulation 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. Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves and other non- neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring).
Documentation must clearly support the medical necessity of electrical stimulation more than 12 visits as adjunctive therapy or for muscle retraining.

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 the clinic.

Non-covered Indications

  • Electrical Stimulation used in the treatment of facial nerve paralysis, commonly known as Bell’s palsy (CMS Manual 100-03, Medicare National Coverage Determinations (NCD) Manual, section 160.15)
  • Electrical Stimulation used to treat motor function disorders such as multiple sclerosis (CMS Manual 100-03, Medicare National Coverage Determinations (NCD) Manual, section 160.2)
  • Electrical Stimulation for the treatment of strokes when it is determined there is no potential for restoration of function
  • 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.


Supportive Documentation Recommendations for electrical stimualtion

  • 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


Electric current therapy
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. Good hygiene measures, extra-strength antiperspirants (for axillary hyperhidrosis), and topical aluminum chloride should initially be tried.

Contrast baths 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 for reimbursement of this code. 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.
This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment.
No more than 2 visits will generally be covered to educate the patient and/or caregiver in home use, and to evaluate effectiveness. Documentation must support the medical necessity of continued use of this modality for greater than 2 visits.
This is a constant attendance code requiring direct, one-on-one patient contact by the provider. Only the actual time of the provider’s direct contact with the patient is to be billed.

Supportive Documentation Recommendations 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.

Covered ultrasound may be pulsed or continuous width, and should 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.


Ultrasound application is not considered reasonable and necessary 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, and/or for extended period of time (e.g., devices such as PainShield MD);
  • wounds.


Phonophoresis (the use of ultrasound to enhance the delivery of topically applied drugs) will be reimbursed as ultrasound. Separate payment will not be made for the contact medium or drugs.
Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound. Do not bill for both ultrasound and electrical stimulation for the same time period.
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 ultrasound. Documentation must clearly support the need for ultrasound more than 12 visits.
Supportive Documentation Recommendations 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


Hydrotherapy
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.

Qualified professional/auxiliary personnel one-on-one supervision of the patient is required. If the level of care does not require the skills of a therapist, then the service is not covered.
Hubbard tank treatments more than 12 visits require clear documentation supporting the medical necessity of continued use of this modality.
It is not medically necessary to have more than one form of hydrotherapy during a visit.
Supportive Documentation Recommendations for hydrotherapy

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


Unlisted Physical therapy treatment (Specify type and time if constant attendance)
If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the claim and medical record must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information.
Note: Low level/cold laser light therapy (LLLT) is considered not reasonable and necessary under SSA 1862(a)(1)(A) and is not payable by Medicare. This procedure is considered non-covered billed under any HCPCS/CPT codes, including S8948 and 97039.
Supportive Documentation Recommendations for unlisted physical therapy treatment
Please see the Unlisted Procedure Codes section of article A56566 Billing and Coding: Outpatient Physical and Occupational Therapy Services, for specific billing instructions.

Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
See instructions for manual electrical stimulation.

Most non-wound care electrical stimulation treatment provided in therapy is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.
The code for electrical stimulation (unattended) is classified as a “supervised” modality, even though it is labeled as “unattended.” A supervised modality does not require direct (one-on-one) patient contact by the provider. Most electrical stimulation conducted via the application of electrodes is considered unattended electrical stimulation. Examples of unattended electrical stimulation modalities include Interferential Current (IFC), Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle stimulation (Russian stimulation).
These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement. Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves, and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring).
If unattended electrical stimulation is used for control of pain and swelling, there should be documented objective and/or subjective improvement in swelling and/or pain within 6 visits. If no improvement is noted, a change in treatment plan (alternative strategies) should be implemented or documentation should support the need for continued use of this modality.
Documentation must clearly support the need for electrical stimulation more than 12 visits. Some patients can be trained in the use of a home TENS unit for pain control. Only 1-2 visits should be necessary to complete the training. Once training is completed, the electrical stimulation (unattended) code should not be billed as a treatment modality in the clinic.

Non-Implantable Pelvic Floor Electrical Stimulation
(CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8.)
Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed with manual electrical stimulation code. Stimulation delivered via electrodes should be billed as electrical stimulation (unattended).

  • The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatments days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.
  • Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary 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 pelvic muscle exercises designed to increase periurethral muscle strength.
  • The patient's medical record must indicate that the patient receiving a non- implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training. Documentation should also include the method of delivery (e.g., probe or electrode).


The charges for the electrodes are included in the practice expense portion of the electrical stimulation (unattended) code. Do not bill the Medicare contractor or the patient for electrodes used to provide electrical stimulation as a clinic modality.


 
Supportive Documentation Recommendations for electrical stimulation (unattended)

  • Type of electrical stimulation used (e.g., TENS, IFC)
  • Area(s) being treated
  • If used for pain include pain rating, location of pain, effect of pain on function



THERAPEUTIC PROCEDURES

General Guidelines for Therapeutic Procedures


Use of these procedures requires the qualified professional/auxiliary personnel to have direct (one-on-one) patient contact. Only the actual time of direct contact with the patient providing a service which requires the skills of a therapist is considered for coverage. Supervision of a previously taught exercise or exercise program, patients performing an exercise independently without direct contact by the qualified professional/auxiliary personnel, or use of different exercise equipment without requiring the intervention/skills of the qualified professional/ auxiliary personnel are not covered. The patient may be in the facility for a longer period of time, but only the time the qualified professional/auxiliary personnel is actually providing direct, one-on-one, patient contact which requires the skills of a therapist is considered covered time for these procedures, and only those minutes of treatment should be recorded.
Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code; there is no separate coverage for time spent on documentation (except for standard cognitive performance testing).
The expected goals documented in the treatment plan, affected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any one or a combination of these procedures may be used in a treatment plan, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

Therapeutic exercises
Therapeutic exercises are used for the purpose of restoring or maintaining strength, endurance, range of motion and flexibility where loss or restriction is a result of a specific disease or injury and has resulted in a functional limitation. Therapeutic exercises may require active, active-assisted, or passive participation by the patient (e.g., isokinetic exercise, lumbar stabilization, stretching and strengthening).
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.
For example, as part of the initial therapy program following total knee arthroplasty (TKA), a patient may start a session on the exercise bike to begin gentle range of motion activity. Initially the patient requires skilled progression in the program from pedal-rocks, building to full revolutions, perhaps assessing and varying the seat height and resistance along the way. Once the patient is able to safely exercise on the bike, no longer requiring frequent assessment and progression, even if set up is required, the bike now becomes an “independent” program and is no longer covered by Medicare. While the qualified professional/auxiliary personnel may still require the patient to “warm up” on the bike prior to other therapeutic interventions, it is considered a non- skilled, unbillable service and should not be included in the total timed code treatment minutes. Non-skilled interventions need not be recorded in the Treatment Notes as they are not billable. However, notation of non-skilled exercises may be reported if the documentation indicates that the service was not billed (e.g., not included in the treatment minutes documented).

Exercises to promote overall fitness, flexibility, endurance (in absence of a complicated patient condition), aerobic conditioning, weight reduction, and maintenance exercises to maintain range of motion and/or strength are non-covered. In addition, exercises that do not require, or no longer require, the skilled assessment and intervention of a qualified professional/auxiliary personnel are non-covered. Repetitive type exercises often can be taught to the patient or a caregiver as part of a self-management, caregiver or nursing program.
Documentation should include not only measurable indicators such as functional loss of joint motion or muscle strength, but also information on the impact of these limitations on the patient’s life and how improvement or maintenance in one or more of these measures effects patient function.
Documentation of progress should show the condition is responsive to the therapy chosen and that the response is (or is expected to be) clinically meaningful. Metrics of progress that are functionally meaningful (or obviously related to clinical functional improvement) should be documented wherever possible. For example, long courses of therapy resulting in small changes in range of motion might not represent meaningful clinical progress benefiting the patient’s function.
Documentation should describe new exercises added, or changes made to the exercise program to help justify that the services are skilled. Documentation must also show that exercises are being transitioned as clinically indicated to an independent or caregiver- assisted exercise program (“home exercise program” (HEP)). An HEP is an integral part of the therapy plan of care and should be modified as the patient progresses during the course of treatment. It is appropriate to transition portions of the treatment to an HEP as the patient or caregiver master the techniques involved in the performance of the exercise.
If an exercise is taught to a patient and performed for the purpose of restoring or maintaining functional strength, range of motion, endurance training, and flexibility, code for strength and endurance exercise is the appropriate code. For example, a gym ball exercise used for the purpose of increasing the patient’s strength should be considered as therapeutic exercise when coding for billing. Also, the minutes spent taping, such as McConnell taping, to facilitate a strengthening intervention.
Lack of exercise equipment at home does not make continued treatment in the clinic skilled or reasonable and necessary. The home program may need to be carried out through community resources.
Documentation must clearly support the need for continued therapeutic exercise greater than 12-18 visits.
For many patients a passive-only exercise program should not be used more than 2-4 visits to develop and train the patient or caregiver in performing PROM. Documentation would be necessary to support services beyond this level (such as PROM where these is an unhealed, unstable fracture, or new rotator cuff repair, requiring the skills of a therapist to ensure that the extremity is maintained in proper position and alignment during the PROM).



Supportive Documentation Recommendations for therapeutic exercises

  • Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on function
  • If used for pain include pain rating, location of pain, effect of pain on function Specific exercises performed, purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills of a therapist were required
  • When skilled cardiopulmonary monitoring is required, include documentation of pulse oximetry, heart rate, blood pressure, perceived exertion, etc.


Neuromuscular re-education
This therapeutic procedure is provided for the purpose of restoring or maintaining balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation (PNF), BAP’s boards, vestibular rehabilitation, desensitization techniques, balance and posture training).
This procedure may be reasonable and necessary for restoring or maintaining function which has been affected by:

  • loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs, and/or fingers;
  • nerve palsy, such as peroneal nerve injury causing foot drop;
  • muscular weakness or flaccidity as result of a cerebral dysfunction, a nerve injury or disease or having had a spinal cord disease or trauma;
  • poor static or dynamic sitting/standing balance;
  • postural abnormalities;
  • loss of gross and fine motor coordination;
  • hypo/hypertonicity.


If an exercise/activity is taught to the patient and performed for the purpose of restoring or maintaining functional balance, motor coordination, kinesthetic sense, posture, or proprioception for sitting or standing activities, code for neuromuscular re-education would be the appropriate code. For example, a gym ball exercise used for the purpose of improving balance should be considered as neuromuscular reeducation when coding for billing. The minutes spent taping, such as McConnell taping or kinesiotaping techniques, to enhance proprioception would be counted under neuromuscular re-education code.
When therapy is instituted because there is a history of falls or a falls screening has identified a significant fall risk, documentation should indicate:

  • specific fall dates and/or hospitalization(s) and reason for the fall(s), if known; most recent prior functional level of mobility, including assistive device, level of assist, frequency of falls or “near-falls”;
  • cognitive status;
  • prior therapy intervention;
  • functional loss due to the recent change in condition;
  • balance assessments (preferably standardized), lower extremity ROM and muscle strength testing;
  • patient and caregiver training;
  • carry-over of therapy techniques to objectively document progress.


It may not be reasonable and necessary to extend visits for a patient with falls, or any patient receiving therapy services, if the purpose of the extended visits is to:

  • remind the patient to ask for assistance;
  • offer close supervision of activities due to poor safety awareness; remind a patient to slow down;
  • offer routine verbal cues for compensatory or adaptive techniques already taught;
  • remind a patient to use an assistive device;
  • train multiple caregivers; or



In these instances, once the appropriate cues have been determined by the qualified professional/auxiliary personnel, training of caregivers can be provided and the care should be turned over to supportive personnel or caregivers since repetitive cues and reminders do not require the skills of a therapist.
Documentation must clearly support the need for continued neuromuscular reeducation greater than 12-18 visits.

Supportive Documentation Recommendations for neuromuscular re-education

  • Objective loss of ADLs, mobility, balance, coordination deficits, hypo- and hypertonicity, posture and effect on function
  • Specific exercises/activities performed (including progression of the activity), purpose of the exercises as related to function, instruction given, and/or assistance needed, to support that the skills of a therapist were required



Aquatic therapy/exercises
Aquatic therapy refers to any therapeutic exercise, therapeutic activity, neuromuscular re-education, or gait activity that is performed in a water environment including whirlpools, hubbard tanks, underwater treadmills and pools.

This procedure may be reasonable and necessary for the loss or restriction of joint motion, strength, mobility, balance or function due to pain, injury, or illness by using the buoyancy and resistance properties of water.
Aquatic therapy may be considered reasonable and necessary for a patient without the ability to tolerate land-based exercises for rehabilitation. Aquatic therapy exercises should be used to facilitate progression to land based therapy. The qualified professional/personnel auxiliary personnel does not need to be in the water with the patient unless there is an identified safety issue.
Exercises in the water environment to promote overall fitness, flexibility, improved endurance, aerobic conditioning, or for weight reduction are non-covered.
This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).
If continued aquatic exercise is needed, the patient should be instructed in a home program during these visits. Lack of pool facilities at home does not make continued treatment skilled or reasonable and necessary. The home program may need to be carried out through community resources. Documentation must clearly support the need for aquatic therapy greater than 8 visits.

Consider the following points when providing aquatic therapy services.

  • Does your patient require the skills as a therapist, or could the patient achieve their goals through a community-based aquatic exercise program? There are a limited number of therapeutic exercises generally performed in the water. These exercises become repetitive quickly. Once a patient can demonstrate an exercise safely, you may no longer bill Medicare for the time it takes the patient to perform this now independent exercise. If the same exercise is performed over a number of sessions, the documentation must describe the skilled nature of the qualified professional’s/auxiliary personnel’s intervention during the therapeutic exercise to support the ongoing medical necessity.
  • Patients who will not be continuing their water-based program as a maintenance program should be transitioned to land-based exercises as soon as reasonably possible for the patient’s condition.
  • The aquatic therapy treatment minutes counted toward the total timed code treatment minutes should only include actual skilled exercise time that required direct one-on-one patient contact by the qualified professional/auxiliary personnel. Do not include minutes for the patient to dress/undress, get into and out of the pool, etc.
  • Do not bill for the water modality used to provide the aquatic environment, such as whirlpool in addition to aquatic therapy/exercises.
  • See Group Therapy for guidelines when treating more than one patient at the same time in the aquatic environment.



Supportive Documentation Recommendations for Aquatic therapy/exercises

  • Justification for use of a water environment
  • Objective loss of ADLs, mobility, ROM, strength, balance, coordination, posture and effect on function
  • If used for pain include pain rating, location of pain, effect of pain on function
  • Specific exercises/activities performed (including progression of the activity), purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills and of a therapist were required.


Gait training therapy
This procedure may be reasonable and necessary for training patients and instructing caregivers in ambulating patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.

  • Indications for gait training include, but are not limited to:
  • a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation;
  • musculoskeletal trauma, requiring ambulation reeducation;
  • a chronic, progressively debilitating condition for which safe ambulation has recently become a concern;
  • an injury or condition that requires instruction in the use of a walker, crutches, or cane;
  • a patient fitted with a brace or lower limb orthosis or prosthesis and requires instruction in ambulation;
  • a condition that requires retraining in stairs/steps or other uneven surfaces appropriate to home and community function (ramps, inclines, curbs, grass, etc);
  • instructing a caregiver in appropriate guarding and assistive techniques.


Gait training is not considered reasonable and necessary when the skills of a therapist are not needed.
Repetitive walk-strengthening exercise (such as for feeble patients or to increase endurance or gait distance) does not require the skills of the therapist and is considered not reasonable and necessary and is non-covered.
Antalgic gait alone does not support the need for ongoing skilled gait training. Antalgic gait refers to a gait pattern assumed in order to avoid or lessen pain. Limited gait training may be appropriate, when supported as medically necessary in the documentation, to teach the patient improved gait patterns to reduce the stress on the painful area. In most circumstances, as the pain decreases (with or without skilled therapy intervention) the gait will improve spontaneously without the need for skilled gait training intervention.

Documentation must clearly support the need for continued gait training beyond 12-18 visits within a 4-6 week period.

Neuromuscular Electrostimulation - Use for Walking in Patients with Spinal Cord Injury (SCI)  - The type of NMES that is used to enhance the ability to walk of SCI patients is commonly 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. The trial period of physical therapy will enable the physician treating the patient for his or her spinal cord injury to properly evaluate the person's ability to use these devices frequently and for the long term. Physical therapy necessary to perform this training must be directly performed by the physical therapist as part of a one-on-one training program.
The goal of physical therapy must be to train SCI patients on the use of NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy.
Coverage for NMES/FES for walking will be covered in SCI patients with all of the following characteristics:
1. Persons with intact lower motor units (L1 and below) (both muscle and peripheral nerve);
2. 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;
3. Persons that demonstrate brisk muscle contraction to NMES and have sensory perception [of] electrical stimulation sufficient for muscle contraction;
4. Persons that possess high motivation, commitment and cognitive ability to use such devices for walking;
5. Persons that can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes;
6. Persons that can demonstrate hand and finger function to manipulate controls;
7. Persons with at least 6-month post recovery spinal cord injury and restorative surgery;
8. Persons with[out] hip and knee degenerative disease and no history of long bone fracture secondary to osteoporosis; and
9. Persons who have demonstrated a willingness to use the device long-term.

(Italicized information about NMES for walking in SCI patients is from CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 160.12)

ICD-10-CM diagnosis code for paraplegia must be present for payment to be made. However, while paraplegia of lower limbs is a necessary condition for coverage, the nine criteria above are also required.
The code for gait training is the only code to be billed. It must be used for one-on-one face-to-face service provided by the physician or therapist.

Supportive Documentation Recommendations for gait training

  • Objective measurements of balance and gait distance, assistive device used, amount of assistance required, gait deviations and limitations being addressed, use of orthotic or prosthesis, need for and description of verbal cueing
  • Presence of complicating factors (pain, balance deficits, gait deficits, stairs, architectural or safety concerns)
  • Specific gait training techniques used, instructions given, and/or assistance needed, and the patient’s response to the intervention, to demonstrate that the skills of a therapist were required


Massage therapy Massage may be medically necessary as adjunctive treatment to another therapeutic procedure on the same day, which is designed to reduce edema, improve joint motion, or relieve muscle spasm.
Massage chairs, aquamassage tables and roller beds are not considered massage. These services are non-covered.
Massage is not covered as an isolated treatment.
Documentation must clearly support the need for continued massage beyond 6-8 visits, including instruction, as appropriate, to the patient and caregiver for continued treatment.
This code is not covered on the same visit date as manual therapy techniques.
Do not bill massage therapy for percussion for postural drainage.
Supportive Documentation Recommendations for massage therapy

  • Area(s) being treated
  • Objective clinical findings such as measurements of range of motion, description of muscle spasms and effect on function
  • Subjective findings including pain ratings, pain location, effect on function



Physical medicine procedure
If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the claim and medical record must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information.

Supportive Documentation Recommendations for physical medicine procedure
Please see section Documentation Recommendations for Unlisted Procedure Codes.
Please see the Unlisted Procedure Codes section of article A56566 Billing and Coding: Outpatient Physical and Occupational Therapy Services , for specific billing instructions.

Manual therapy

  • Manual traction may be considered reasonable and necessary for cervical dysfunctions such as cervical pain and cervical radiculopathy.
  • Joint Mobilization (peripheral and/or spinal) may be considered reasonable and necessary if restricted or painful joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.
  • Myofascial release/soft tissue mobilization, one or more regions, may be reasonable and necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems.
  • Manipulation, which is a high-velocity, low-amplitude thrust technique or Grade V thrust technique, may be reasonable and necessary for treatment of painful spasm or restricted motion in the periphery, extremities or spinal regions.
  • Manual lymphatic drainage/complex decongestive therapy (MLD/CDT) MLD / CDT is indicated for both primary and secondary lymphedema. Lymphedema in the Medicare population is usually secondary lymphedema, caused by known precipitating factors. 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 often (but not always) be brought under long-term control with proper 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 allowed 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 to severe lymphedema, daily visits are usually required for the first 3-8 weeks.
  • Education should be provided to the patient and/or caregiver on the correct application of the compression bandage.
  • The therapeutic exercise component for MLD / CDT is covered under CPT code therapeutic procedure;strength and endurance.


MLD/CDT is not covered 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.


Documentation must clearly support the need for continued manual therapy treatment beyond 12-18 visits. When the patient and/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 therapy  is not covered on the same visit as this code.
Supportive Documentation Recommendations for Manual therapy

    • Area(s) being treated
    • Soft tissue or joint mobilization technique used
    • Objective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on function
    • For MLD/CDP, supportive documentation should include:
      • medical history related to onset, exacerbation and etiology of the lymphedema
      • comorbidities prior treatment
      • cognitive and physical ability of patient and/or caregiver to follow self- management techniques;
      • pain/discomfort descriptions and ratings;
      • limitation of function related to self-care, mobility, ADLs and/or safety; prior level of function;
      • limb measurements of affected and unaffected limbs at start of care and periodically throughout treatment;
      • description of skin condition, wounds, infected sites, scars.



Group therapeutic procedures Report the group therapy code for each member of the group. Group therapy procedures involve constant attendance of the physician, NPP, therapist, or assistant, but by definition do not require one-on-one patient contact.
Group therapy consists of therapy treatment provided simultaneously to two or more patients who may or may not be doing the same activities. If the therapist is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, one unit is appropriate per patient.

Examples:

  • In a 25-minute period, a therapist works with two patients, A and B, and divides his/her time between the two patients. The therapist moves back and forth between the two patients, spending a minute or two at a time, and provides occasional assistance and modifications to patient A’s exercise program and offers verbal cues for patient B’s gait training and balance activities on the parallel bars. The therapist does not track continuous identifiable episodes of direct one-on-one contact with either patient. The appropriate coverage is one (1) unit for each patient.
  • In a 45-minute period, a therapist works with 3 patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives 8 minutes, patient B receives 8 minutes and patient C received 8 minutes. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18 minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the therapist, they are each exercising independently. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise.


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

Non-covered as group therapy

  • Groups directed by a student, therapy aide, rehabilitation technician, nursing aide, recreational therapist, exercise physiologist, or athletic trainer
  • 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
  • Group treatment that does not require the unique skills of a therapist


If group therapy is billed on a given day, it must be listed in the Treatment Note. The minutes of this untimed code must be added to the Total Treatment Time for that day. Further documentation describing the skilled nature of the group session documented in the progress report or the treatment note may assist in supporting the medical necessity of the service.

Supportive Documentation Recommendations for group therapy

  • The purpose of the group and the number of participants in the group
  • Description of the skilled activity provided in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual.


Therapeutic activities
Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involve movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, pushing, pinching, grasping, transfers, bed mobility and overhead activities) to restore or maintain functional performance. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of the therapist to design the activities to address a specific functional need of the patient and to instruct the patient in their performance. These dynamic activities must be part of an active treatment plan and must be directed at a specific outcome.

In order for therapeutic activities to be covered, the following requirements must be met:

  • the patient has a documented condition for which therapeutic activities can reasonably be expected to restore or maintain functioning;
  • there is a clear correlation between the type of therapeutic activity performed and the patient’s underlying medical condition;
  • the patient’s condition is such that he/she is unable to perform the therapeutic activities without the skilled intervention of the qualified professional/auxiliary personnel.


Documentation must clearly support the need for continued therapeutic activity treatment beyond 10-12 visits.
Supportive Documentation Recommendations for therapeutic activities

  • Objective measurements of loss of ADLs, balance, strength, coordination, range of motion, mobility and effect on function
  • Specific activities performed, and amount and type of assistance to demonstrate that the skills and expertise of the therapist were required


Cognitive skills development
This activity is designed to improve attention, memory, and problem-solving, including the use of compensatory techniques. Cognitive skill training may be medically necessary for patients with acquired cognitive deficits resulting from head trauma, or acute neurologic events including cerebrovascular accidents. Impaired functions may include but are not limited to ability to follow simple commands, attention to tasks, problem solving skills, memory, ability to follow numerous steps in a process, perform in a logical sequence and ability to compute.
Evidence-based reviews indicate that cognitive rehabilitation (and specifically memory rehabilitation) is not recommended for patients with severe cognitive dysfunction.
Cognitive skill training should be aimed towards 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.
Cognitive skills are an important component of many tasks, and the techniques used are integral to the broader impairment being addressed. Cognitive therapy techniques are most often covered as components of other therapeutic procedures, and, typically are better reported using other codes (such as 97535).
Activities billed as cognitive skills development 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. Those services that a patient may engage in without a skilled therapist qualified professional/auxiliary personnel are not covered under the Medicare benefit.
Coverage is limited to the following conditions.

  • Personality change due to known physiological condition
  • Other personality and behavioral disorders due to known physiological condition
  • Pseudobulbar affect
  • Unspecified mental disorder due to known physiological condition
  • Unspecified personality and behavioral disorder due to known physiological condition


Please also add the ICD-10-CM code for the underlying disorder (cause). Note: the restrictions placed upon this code do not apply to vision impairment rehabilitation services as defined in PM AB-02-078.
Supportive Documentation Recommendations for Cognitive skills development

  • Objective assessment of the patient’s cognitive impairment and functional abilities
  • A determination of a range of compensatory strategies that the individual can realistically utilize to in a meaningful way
  • Specific cognitive activities performed, amount of assistance, and the patient’s response to the intervention, to demonstrate that the skills and expertise of the therapist were required


Sensory integration
Sensory integrative techniques are performed to enhance sensory processing and promote adaptive responses to environmental demands. These treatments are performed when a deficit in processing input from one of the sensory systems (e.g., vestibular, proprioceptive, tactile, visual or auditory) decreases an individual’s ability to make adaptive sensory, motor and behavioral responses to environmental demands.
Individuals in need of sensory integrative treatments demonstrate a variety of problems, including sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems.
Sensory integration treatments are often associated with pediatric populations. For non- pediatric patients, these services may be medically necessary for acquired sensory problems resulting from head trauma, illness, or acute neurologic events including cerebrovascular accidents. Therapy is not considered a cure for sensory integrative impairments, but is used to facilitate the development of the nervous system’s ability to process sensory input differently.
Utilization of this service should be infrequent for Medicare patients.
Supportive Documentation Recommendations for sensory integration

  • Objective assessments of the patient’s sensory integration impairments and functional limitations
  • Describe the treatment techniques used that will promote adaptive responses to environmental demands, and the patient’s response to the intervention, to support that the skills of a therapist were required


Self–care management training
This procedure is reasonable and necessary only when it requires the skills of a therapist, is designed to address specific needs of the patient, and is part of an active treatment plan directed at a specific outcome.
The patient must have a condition for which self-care/home management training is reasonable and necessary. The training should be focused on a functional limitation(s) that will be meaningful to the patient and the caregiver. The patient and/or caregiver must have the capacity and willingness to learn from instructions. Documentation must relate the training to expected functional goals.
This code 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. See more specific codes for exercise training, orthotics, gait devices, etc.
This code should not be used globally for all home instructions. When instructing the patient in a self management program, use the code that best describes the focus of the self management activity.
Services provided to the same patient by physical therapy and occupational therapy may be covered if separate and distinct goals are documented in the treatment plans and there is no duplication of services.
Many ADL/IADL impairments 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, repetitious completion of the activity, once taught and monitored, is non-covered care.
For example, as part of the initial occupational therapy program following a total hip arthroplasty (THA), a patient may need to learn adaptive lower extremity dressing techniques due to pain, limited ROM and hip precautions. The occupational therapist will need to evaluate the patient to determine the appropriate technique to be taught based on the patient’s unique assessment and will instruct the patient and/or caregiver in the special technique. Once the special dressing technique has been taught and monitored for safe completion, repetitious carrying out or practicing of the dressing technique would be considered non-skilled and would not be covered. Non-skilled interventions need not be recorded in the Treatment Notes as they are not billable. However, notation of non-skilled activities may be reported if the documentation indicates that the service was not billed (e.g., not included in the treatment minutes documented).

As the patient progresses through an episode of care involving self care/home management training, documentation needs to clearly support that the skills of a therapist continue to be necessary. It is important that documentation demonstrates that the skills of a therapist are needed and that the patient is not merely practicing techniques that have already been taught.

Supportive Documentation Recommendations for self-care management

  • Objective measurements of the patient’s activity of daily living (ADL)/instrumental activity of daily living (IADL) impairment to be addressed
  • The specific ADL and/or compensatory training provided, specific safety procedures addressed, specific adaptive equipment/assistive technology utilized, instruction given and assist required (verbal or physical), and the patient’s response to the intervention, to support that the services provided required the skills and expertise of a therapist


Community/work reintegration
For wheelchair management/propulsion training use appropriate wheelchair management CPT code.
This code should be utilized when a patient is trained in the use of assistive technology to assist with mobility, seating systems and environmental control systems for use in the community.
General activity programs, and all activities which are primarily social or diversional in nature, will be denied because the professional skills of a therapist are not required. Services must be necessary for medical treatment of an illness or injury rather than related solely to specific leisure or employment opportunities, work skills or work settings.
Coverage greater than 4-6 visits for community training should be justified by documentation to show the medical necessity of the length of treatment.
Supportive Documentation Recommendations for Community/work reintegration

  • Objective measurements of the patient’s community IADL impairment to be addressed
  • Specific training provided, amount of assist required (verbal or physical), and the patient’s response to the intervention, to support that the services rendered required the skills of a therapist


Wheelchair management training
This code is used to reflect the skilled wheelchair management intervention clinicians provide related to the assessment, fitting and/or training for patients who must utilize a wheelchair for mobility. This service trains the patient, family and/or caregiver in functional activities that promote safe wheelchair mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.
CPT Changes 2006 – An Insider’s View provides further clarification regarding the assessment portion of this code. A wheelchair assessment may include but is not limited to the patient’s strength, endurance, living situation, ability to transfer in and out of the chair, level of independence, weight, skin integrity, muscle tone, and sitting balance. Following verification of the patient’s need, patient measurements are taken of the patient prior to ordering the equipment to ensure accuracy of sizing wheelchair components. This measurement may also involve testing the patient’s abilities with various chair functions including propulsion, transferring from the chair to other surfaces (bed, toilet, car), and use of the chair’s locking mechanism on various types of equipment for optimal determination of the appropriate equipment by the patient and caregiver.
For example, when assessing and fitting the patient with a wheelchair and custom seating system to provide stabilization, support, balance, and pressure management. Would also be used when training the patient in the safe operation and management of the wheelchair in the home and community environment. (This example is based upon the Clinical Example for in the CPT Changes 2006 – an Insider’s View.)
There may be circumstances where a patient may be seen one time for a wheelchair assessment. If it is not necessary to complete a full patient evaluation, but only an assessment related to specific wheelchair needs, this one-time only session may be billed with the appropriate units reflecting the time spent in the assessment.
For many patient situations however, a full patient evaluation is needed to develop the appropriate treatment plan in addition to wheelchair fitting and training. In these situations, it may be appropriate to bill the initial evaluation code. On the day that the evaluation code is billed, the minutes assigned to wheelchair management should only be related to any wheelchair fitting and training provided, as this is a timed code. For example, if a physical therapist spends 35 minutes gathering the patient history, prior functional status, current functional status, social considerations, range of motion, strength, sensation, balance, and transfers, this time would be assigned to the PT initial evaluation. As the session continues, the PT spends 45 minutes assessing the patient in a variety of wheelchair set ups, trying a variety of adaptations to best meet the patient’s comfort and functional needs, and initiates training with the patient and family, this 45 minutes would be assigned to the wheelchair management code.


Consider the following points when providing wheelchair management services.

  • Assessment for cushions, lapboards, wheelchair trays, or lap buddies for a patient without a complicating condition typically does not require the unique skills of a therapist.
  • A seating assessment is not medically necessary for every patient.
  • Skilled intervention would not be necessary for wheelchair issues that the patient can self-correct.
  • The patient/caregiver must have the capacity and willingness to learn from instructions.
  • When wheelchair and seating assessments are reasonable, care should be turned over to supportive personnel or a caregiver once the necessary modifications are successfully implemented.
  • Ongoing visits for increasing sitting times are generally not reasonable and necessary when no patient problems are documented.
  • Visits made for restraint reduction are generally non-covered.
  • It is expected that multiple wheelchair and seating deficits discovered during the initial evaluation would be treated concurrently. If not, documentation must indicate that a new problem/deficit occurred, or include rationale why a problem being treated in the later stages of therapy was not addressed previously.


Typically up to 3-4 dates of service should be sufficient to train the patient/caregiver in wheelchair management. Coverage beyond this utilization should have supportive documentation that clearly demonstrates the need for additional visits.
Supportive Documentation Recommendations for wheelchair management

    • Documentation for a skilled wheelchair assessment should include the following:
      • the recent event that prompted the need for a skilled wheelchair assessment; any previous wheelchair assessments have been completed, such as during a Part A SNF stay;
      • most recent prior functional level;
      • if applicable, any previous interventions that have been tried by nursing staff, caregivers or the patient that may have failed, prompting the initiation of skilled therapy intervention;
      • functional deficits due to poor seating or positioning;
      • objective assessments of applicable impairments such as range of motion (ROM), strength, sitting balance, skin integrity, sensation and tone;
      • the response of the patient or caregiver to the fitting and training.

 

  • When billing for wheelchair management/training, documentation must relate the training to expected functional goals that are attainable by the patient and /or caregiver.
  • Describe the interventions to show that the skills of a therapist were required. For example, describe the various wheelchair adaptations trialed and the patient’s response to the intervention. If training is provided, describe the type of training, the amount of assistance required and the patient response to the training.


Work hardening/conditioning and each additional hour
These services are related solely to specific work skills and will be denied as not medically necessary for the diagnosis or treatment of an illness or injury.


 Rmvl devital tis 20 cm/<
 Rmvl devital tis addl 20 cm< 
Wound(s) care non-selective

Active wound care procedures are performed to remove devitalized tissue and promote healing, and involve selective and non-selective debridement techniques. Debridement is indicated whenever necrotic tissue is present in an open wound. Debridement may also be indicated in cases of abnormal wound healing or repair. Debridement will not be considered a reasonable and necessary procedure for a wound that is clean and free of necrotic tissue.
The wound care performed must be in accordance with accepted standards of medical practice. If debridement is performed, the type of debridement should be appropriate to the type of wound and the devitalized tissue, and the patient’s condition. Not all wounds require debridement at each session or the same level of debridement at each session. It is unusual to debride more than one time per week for more than three months. A greater frequency or duration of selective debridement should be justified in the documentation. Most very small wounds do not require selective debridement. Ulcers that may require selective debridement are typically larger than 2 x 2 cm. Wounds with tunneling, regardless of size, may require selective debridement. Selective debridement is usually not reasonable and necessary for blisters, ulcers smaller than those described above and uninfected ulcers with clear borders.
Documentation for each treatment must include a detailed description of the procedure and the method (e.g., scalpel, scissors, 4x4 gauze, wet-to-dry, enzyme). Because the correct debridement code is dependent on type of debridement and wound size, documentation should include frequent wound measurements. The documentation should also include a description of the appearance of the wound (especially size, but also depth, stage, bed characteristics), as well as the type of tissue or material removed. The documentation must meet the criteria of the code billed.
Medicare coverage for wound care on a continuing basis for a particular wound requires documentation in the patient's record that the wound is improving in response to the wound care being provided. It is not medically reasonable or necessary to continue a given type of wound care if evidence of wound improvement cannot be shown.

Evidence of improvement includes measurable changes (decreases) in at least some of the following:

  • drainage;
  • inflammation;
  • swelling; pain;
  • wound dimensions (diameter, depth);
  • necrotic tissue/slough.


Such evidence must be documented periodically (e.g. weekly.) A wound that shows no improvement after 30 days requires a new approach, which may include a physician/NPP reassessment of underlying infection, metabolic, nutritional, or vascular problems inhibiting wound healing, or a new treatment approach.
In rare instances, the goal of wound care provided in outpatient settings may be only to prevent progression of the wound, which, due to severe underlying debility or other factors such as inoperability, is not expected to improve. If this is the case, documentation should clearly indicate this rationale for continued skilled wound care.
Examples of Selective Debridement (without anesthesia)

  • Conservative Sharp Debridement: Conservative sharp debridement is a minor procedure that requires no anesthesia. Scalpel, scissors, forceps, or tweezers may be used and only clearly identified devitalized tissue is removed. Generally, there is no bleeding associated with this procedure.
  • High Pressure Water Jet Lavage: (non-immersion hydrotherapy) is an irrigation device, with or without pulsation used to provide a water jet to administer a shearing effect to loosen debris, within a wound. Some electric pulsatile irrigation devices include suction to remove debris from the wound after it is irrigated.


Examples of Non-Selective Debridement(without anesthesia)  include the following items.

  • Blunt debridement
  • Blunt debridement involves the removal of necrotic tissue by cleansing or scraping (abrasion). It may also involve the cleaning and dressing of small or superficial lesions.
    • Enzymatic debridement
    • Debridement with topical proteolytic enzymes is used as an adjunctive therapy in treating chronic wounds. The manufacturers’ product insert contains indications, contraindications, precautions, dosage and administration guidelines; it is the clinician’s responsibility to comply with those guidelines. 
  • Wet-to-moist dressings
  • Wet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing. 
  • Autolytic and chemical debridement


Additional guidance for debridement codes

  • These codes are not timed.
  • Do not bill for more than one unit per session, regardless of the number or complexity of the wounds treated.
  • Do not bill for both selective wound debridement and devitalized tissue for the same wound.
  • Use the -59 modifier to indicate nonselective and selective debridement provided in a single encounter at different anatomical sites.
  • Application and removal of dressings to the wound is included in the work and practice expenses and should not be billed separately under a therapy plan of care. Charges for dressings, gauze, tape, sterile water for irrigation, tweezers, scissors, q-tips, and medications used in the wound care treatment will be denied even if the wound care service is found to be medically reasonable and necessary. Payment for dressings applied to the wound is included and they are not to be billed separately. If a simple dressing change is performed without any active wound procedure as described by these codes, do not bill these codes to describe the service.
  • For wound assessment it is not appropriate to bill therapy re-evaluation codes along with codes the selective wound debridement and devitalized tissue codes. The assessment, including measurements of the wound and a written report, is considered a part of the codes.
  • Whirlpool and selective wound debridement  should not be billed together as the whirlpool treatment is a component of the selective wound debridement code (unless there is a separately identifiable condition being treated and documentation supports this treatment).
  • Patient and caregiver instructions are included in the codes. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.
  • These codes represent “sometimes therapy” services and will be paid under the OPPS when (a) the service is not performed by a therapist, and (b) it is inappropriate to bill the service under a therapy plan of care. Nurses performing debridement (where allowed by state scope of practice acts) described by codes for selective wound debridement and devitalized tissue may bill these codes using revenue codes other than the therapy revenue codes 42x (PT) and 43x (OT).
  • Payment for devitalized tissue, when performed by a qualified professional/auxiliary personnel under a therapy plan of care, is recognized as a bundled service under the Medicare Physician Fee Schedule (MPFS). Regardless of whether billed alone or in conjunction with another therapy code, separate payment is never made.
  • Evaluation and management services should not be billed along with the debridement service unless a significant, separately identifiable evaluation and management service, correctly identified with modifier -25 on the claim, was also provided to the patient during the same encounter. (Therapists should not use the evaluation and management codes at any time.)


Supportive Documentation Recommendations for selective wound debridement and devitalized tissue

  • Etiology and duration of wound
  • Prior treatment by a physician, non-physician practitioner, nurse and/or therapist Stage of wound
  • Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate
  • Evidence of infection, undermining, or tunneling Nutritional status
  • Comorbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use
  • Patient’s functional level
  • Skilled plan of treatment, including specific frequency, modalities and procedures Type of debridement performed, including instrument used, to support the debridement code billed
  • Changing plan of treatment based on clinical judgment of the patient’s response or lack of response to treatment
  • Frequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.


Note: While debridement is considered a covered service for appropriately selected wounds, the following services are considered non-covered for the treatment of wounds.

  • Topical application of oxygen (CMS Publication 11-03, Medicare National Coverage Determinations (NCD) Manual, section 270.4.)
  • Ultrasound
  • Infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE) (CMS Publication 11-03, Medicare National Coverage Determinations (NCD) Manual, section 270.6.)
  • Low Level Laser Treatment (LLLT) Magnet therapy
  • Autologous blood-derived products for chronic, non-healing wounds (CMS Publication 11-03, Medicare National Coverage Determinations (NCD) Manual, section 270.3.)
  • Routine dressing changes
  • Non-Contact Normothermic Wound Therapy (NNWT) (CMS Publication 11-03, Medicare National Coverage Determinations (NCD) Manual, section 270.2.)




Neg press wound tx < 50 cm CPT

Neg press wound tx > 50 cm

Neg press wound tx<50cm

Neg press wound tx >50 cm


Negative pressure wound therapy (NPWT) involves negative pressure to the wound bed to manage wound exudates and promote wound healing. The FDA defines a system that promotes healing in various types of open wounds by removing wound fluids and waste materials (debris) through the creation of a vacuum (negative pressure) at a well-sealed wound site. NPWT may also help with wound healing by drawing wound edges together.
NPWT systems consist of the following parts: a pump that generates a vacuum and is capable of creating a negative pressure environment within a sealed wound; dressing materials used to pack the wound and seal it; tubing for fluid removal from the wound area; and a container/canister to collect waste materials that are removed from the wound area by suction.
NPWT is indicated for use as an adjunct to standard treatment in carefully selected patients who have failed all other forms of treatment. NPWT may be indicated for wounds such as:

  • Stage III or IV pressure ulcers;
  • Neuropathic (for example, diabetic) ulcers;
  • Chronic arterial or venous insufficiency ulcers;
  • Complications of surgically created or traumatic wounds.


NPWT is not covered for:

  • Stage I or II pressure ulcers;
  • Wounds with eschar present;
  • Untreated osteomyelitis within the vicinity of the wound;
  • Malignancy present in the wound;
  • Exposed vasculature;
  • Exposed nerve(s);
  • Exposed anastomotic site;
  • Exposed organ(s);
  • Active bleeding;
  • The presence of a fistula to an organ or body cavity within the vicinity of the wound.



The FDA has issued a Safety Communication titled "UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems" dated 24 February 2011.
Any provider using NPWT therapy should be fully aware of the findings and recommendations contained therein. An internet link to this communication may be found under the Sources of Information and Basis for Decision header below.

Additional guidance for NPWT codes

  • These codes are not timed.
  • Do not bill for more than one unit per session, regardless of the number or complexity of the wounds treated.
  • Patient and caregiver instructions are included in the codes. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.
  • It is not appropriate to bill therapy re-evaluation codes along with Negative Pressure Wound Therapy Systems. The assessment, including measurements of the wound and a written report, is considered a part of the code.


Supportive Documentation Recommendations for Negative Pressure Wound Therapy Systems

  • Etiology and duration of wound
  • Prior treatment by a physician, non-physician practitioner, nurse and/or therapist Stage of wound
  • Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate
  • Evidence of infection, undermining, or tunneling Nutritional status
  • Comorbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use
  • Patient’s functional level
  • Skilled plan of treatment, including specific frequency, modalities and procedures Changing plan of treatment based on clinical judgment of the patient’s response or lack of response to treatment
  • Frequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.


Physical performance test
Physical performance testing may be reasonable and necessary for patients with neurological, musculoskeletal, or pulmonary conditions. These tests and measurements are beyond the usual evaluation services performed. Examples of physical performance tests or measurements include isokinetic testing, Functional Capacity Evaluation (FCE) and Tinetti. This code may be used for the 6-minute walk test, with a computerized report of the patient’s oxygen saturation levels with increasing stress levels, performed under a PT or OT plan of care on pulmonary rehabilitation patients.
The therapy evaluation and re-evaluation codes are for a comprehensive review of the patient including, but not limited to, history, systems review, current clinical findings, establishment of a therapy diagnosis, and estimation of the prognosis and determination and/or revision of further treatment. The physical performance test is intended to focus on patient performance of a specific activity or group of activities (CPT Assistant, December 2003).
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 reasonable and necessary for the test to be performed and billed on a routine basis (i.e., monthly or instead of billing a reevaluation) or to be routinely performed on all patients treated. It should not be used to bill for patient assessments/re- assessments such as 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) and/or as the patient progresses through the episode of treatment.

Supportive Documentation Recommendations for physical performance test 

  • Problem requiring the test and the specific test performed
  • Separate measurement report, including any graphic reports
  • Application to functional activity
  • How the test impacts the plan of care



Assistive technology assess
The provider performs an assessment of the suitability and benefits of acquiring any assistive technology device or equipment that will help restore, augment, or compensate for existing functional ability in the patient (e.g., provision of large amounts of rehabilitative engineering).
Coverage is specifically for assessment of mobility, seating and environmental control systems that require high level adaptations, not for routine seating and mobility systems (e.g., manual/power wheelchair evaluations).
This is an assessment code, per each 15 minutes, and must be accompanied by a written report explaining the nature and complexity of the assistive technology needed by the patient. This can include testing multiple components/systems to determine optimal interface between client and technology applications, and determining the appropriateness of commercial (off the shelf) or customized components/systems. This assessment may require more than one patient visit due to the complexity of the patient’s condition and his/her decreased tolerance for activity at one session.
Training for use in assistive technology in the home environment has a different code for use in the community.

Utilization of this service should be infrequent.
Supportive Documentation Recommendations for Assistive technology assess

  • The goal of the assessment
  • The technology/component/system involved
  • A description of the process involved in assessing the patient’s response
  • The outcome of the assessment
  • Documentation of how this information affects the treatment plan



Orthotic management and training
Gait training for the use of the orthotic is included in the fee for orthotic management and training. If gait training is necessary for purposes other than the use of the orthotic then the documentation shall clearly show the reasons for same.

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 and/or caregivers 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.
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 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.
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.
Outpatient hospital therapy departments, comprehensive outpatient rehabilitation facilities (CORFs), outpatient rehabilitation facilities, nursing homes (limited to patients covered under a Medicare Part B stay), and home health agencies (limited to patients not under a HH plan of care) bill the Part A MAC for the orthotic utilizing the relevant HCPCS Level II L code and revenue code 274 on the claim form. These settings do not require a DME supplier billing enrollment to bill and be reimbursed for the L codes.
A physical or occupational therapist in private practice or a physician/NPP is considered by Medicare to be a "supplier" and must bill the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for orthotics. Any supplier that issues orthotics must be enrolled as a supplier of Durable Medical Equipment, Prosthetics, Orthotics, or Supplies (DMEPOS) prior to billing the DME MAC. Follow the directions from the DME MAC when billing for orthotics (utilizing an L code). Note: Therapists in private practice and physicians/NPPs should follow the guidance below for billing to the Medicare carrier/Part B MAC.
Payment for prosthetics and orthotics is made on the basis of a fee schedule whether it is billed to the DME MAC or the FI/Part A MAC.
The L codes for orthotics provide a brief description of the device and describe whether the device needs to be molded to a patient model, custom fabricated, custom fitted, or have no fitting specifications. Select the appropriate L code based on the description of the brace provided.
The Medicare payment for the L codes includes the following items.

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


The appropriate CPT code should be used for orthotic "training" completed by qualified professionals/auxiliary personnel. The code may be used in conjunction with the L code only for the time spent training the patient in the use of 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. To avoid duplicate billing, the time spent assessing, measuring and/or fitting, fabricating or modifying, or making the orthotic may not be included in calculating the number of units to bill when also billing the appropriate L code. The code for orthotic training is a "timed" code and only minutes actually spent in the training of the patient should be counted when determining units to bill when an L code is also billed.
There may be circumstances where a patient is only going to be seen for a brief therapy episode for issuance of an orthotic. If it is not necessary to complete a full, comprehensive patient evaluation, but only an assessment related to determining the specific orthotic, do not bill an initial therapy evaluation code in addition to the L code.
For other patient situations however, a full patient initial evaluation is needed to develop the appropriate treatment plan in addition to an assessment related to determining the specific orthotic. In these situations, it may be appropriate to bill the initial evaluation code with the minutes spent for the evaluation assigned to the code. For example, a patient is referred to occupational therapy for a wrist- hand orthotic with possible continued therapy. The OT spends 35 minutes evaluating the patient which includes the history, subjective complaints, prior and current functional levels, ROM, strength, sensation, skin integrity, and ADL assessment. This time would be assigned to the OT evaluation codes. The OT then begins the assessment of the patient for the orthotic which includes determining the need for the orthotic and the type of orthotic, subsequently fabricating the appropriate device and fitting it to the patient. This time, which takes 45 minutes, would be reimbursed under the L code. The OT spends an additional 20 minutes training the patient in the wearing schedule of the orthotic, skin care and exercises to be performed while the orthotic is in place.

Per CPT Assistant, February 2007, “Orthotic management code includes additional orthotic management and training during follow-up visits including exercises performed in the orthotic, instruction in skin care and orthotic wearing time, and time associated with modification of the orthotic due to healing of tissues, change in edema, or interruption in skin integrity.”
For an orthotic to be billed, it must be medically necessary for the patient's condition. To bill for training the patient to use the orthotic  the documentation must justify the need for a 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 and/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 necessary for the patient's condition.
For uncomplicated conditions, the following services would not be considered 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)


Repetitive range of motion prior to placing an orthotic/positioner to maintain the range of motion is not reasonable and necessary when the therapeutic intent is primarily to maintain range of motion within a chronic condition.
Ongoing therapy visits for increasing wearing time are generally not 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 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.
Coverage 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.
It is not appropriate to bill for measurements taken to obtain custom fitted burn or pressure garments. These garments do not fit the definition of an orthotic.
Supportive Documentation Recommendations 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
Prosthetic training includes preparation of the stump, skin care, modification of prosthetic fit (revisions to socket liner or stump socks), and initial mobility and functional activity training. Once a patient begins gait training with the prosthesis, use code for therapeutic procedure; gait training.
Supportive Documentation Recommendations for prosthetic training

  • Type of prosthesis, extremity involved
  • Specific training provided and amount of assistance needed
  • Any complicating factors and specific description of these (with objective measurements), such as pain, joint restrictions/contractures, strength deficits, etc.



C/o for orthotic/prosth use

These assessments are intended for established patients who have already received their orthotic or prosthetic device.
These assessments of the response to wearing the device may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls). According to CPT Assistant – February 2007, code for orthotic prosthetic includes patient’s response to wearing the device, whether the patient is donning/doffing the device correctly, patient’s need for padding, under wrap, or socks, and of the patient’s tolerance to any dynamic forces being applied.
If the checkout assessment resulted in the need for further training in the use of the orthotic/prosthetic, would be appropriate for the training.
These assessments may not be considered reasonable and necessary when a device is newly issued or when a device is reissued or replaced after normal wear and no modifications are needed.
Documentation must clearly support the need for more than 2 visits for the checkout assessment.
This is not covered on the same date as CPT codes an evaluation.
Supportive Documentation Recommendations for orthotic/prosth use

  • Reason for assessment
  • Findings from the assessment
  • Specific device, modifications made, instruction given


Physical medicine procedure
If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the claim and medical record must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information.
Supportive Documentation Recommendations for physical medicine
Please see Documentation Requirements for Unlisted Procedure codes. This is an untimed code, billable as "1" unit.
Please see the Unlisted Procedure Codes section of article A46198, Outpatient Physical and Occupational Therapy Services – Supplemental Instructions Article, for specific billing instructions.

Electrical stimulation, (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care

Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care



 Nationally Covered Indications (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 270.1): Electrical stimulation (ES) and electromagnetic therapy for the treatment of wounds are considered adjunctive therapies, and will only be covered for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers. Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence. ES or electromagnetic therapy will be covered only after appropriate standard wound therapy has been provided for at least 30 days and there are no measurable signs of healing. This 30-day period may begin while the wound is acute.
Standard wound care includes optimization of nutritional status, debridement by any means to remove devitalized tissue, maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings, and necessary treatment to resolve any infection that may be present. Standard wound care based on the specific type of wound includes frequent repositioning of a patient with pressure ulcers (usually every 2 hours), off-loading of pressure and good glucose control for diabetic ulcers, establishment of adequate circulation for arterial ulcers, and the use of a compression system for patients with venous ulcers.
Measurable signs of healing include a decrease in wound size (either surface area or volume), decrease in amount of exudates, and decrease in amount of necrotic tissue. ES or electromagnetic therapy must be discontinued when the wound demonstrates a 100% epithelialized wound bed.
ES and electromagnetic therapy services can only be covered when performed by a therapist, a physician or incident to a physician’s service.
Evaluation of the wound is an integral part of wound therapy. When providing ES or electromagnetic therapy, the therapist must evaluate and frequently reassess the wound, contacting the treating physician if the wound worsens (do not bill a re- evaluation code for the wound assessment). If ES or electromagnetic therapy is being used, wounds must be evaluated at least monthly by the treating physician.
Per NCD 270.1, electrical stimulation and electromagnetic therapy are NOT COVERED for the treatment of:

  • stage I or stage II wounds;
  • electrical stimulation or electromagnetic therapy when used as an initial treatment modality;
  • continued treatment with ES or electromagnetic therapy if measurable signs of healing have not been demonstrated within any 30-day period of treatment;
  • wounds that demonstrate a 100% epithelialized wound bed;
  • a patient in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary.


Supportive Documentation Recommendations for Electrical stimulation, (unattended) and G0329

  • Etiology and duration of wound
  • Type of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatment
  • Stage of wound
  • Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate
  • Evidence of infection, undermining, or tunneling Nutritional status
  • Comorbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use
  • Patient’s functional level
  • Skilled plan of treatment, including specific frequency of the modality
  • Changing plan of treatment based on clinical judgment of the patient’s response or lack of response to treatment
  • Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session)



Electrical stimulation, (unattended), to one or more areas, for wound care other than described from above
This code is not covered by Medicare.
Other Available Therapy Codes

Muscle and Range of Motion Testing
For the typical patient, the evaluation  and reevaluation codes  include all the necessary evaluation tools, including range of motion and manual muscle testing. Baseline measurements may be done with an initial evaluation, but are not separately billable in addition to the evaluation. In addition, assessments, which are separate from evaluations and reevaluations, are included in the therapy treatment services and procedures and should be coded consistent with the intervention for which the assessment is necessary.
Assessments must be provided by therapists or physician/NPP (not therapy assistants) and include objective testing and measurement (such as ROM and manual muscle testing) to make clinical judgments regarding the patient’s condition to determine the next step in the treatment plan.

On rare occasions, it may be appropriate to perform a thorough range of motion or manual muscle test during the course of treatment that is separate from the evaluation/reevaluation. Patients with complicated conditions may warrant specialized tests and measures with standardized reports. For example, a patient with an incomplete C5 quadriplegia at six months post-injury may need specialized testing for ROM or strength measurements to address specific deficits and goals.
Testing must be pertinent to the plan of care and the diagnosis.
Every muscle or joint in the affected extremity or trunk section, as described in the code descriptor, must be tested when coding these procedures. For example:

  • “Muscle testing, manual with report: extremity (excluding hand) or trunk”. To use this code for extremity manual muscle testing, every muscle of at least one extremity would need to be tested, with documentation of why such a thorough assessment was warranted. It would not be appropriate to bill the code if only hip strength needed to be tested.
  • “Range of motion measurements and report; each extremity (excluding hand) or trunk section (spine)”. To use this code for extremity ROM testing, every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted. It would not be appropriate to bill the code if only shoulder ROM needed to be tested.


It is not reasonable or necessary for these codes to be performed on a routine basis or to be routinely used for all patients (e.g., monthly or in the place of billing for a reevaluation).


Supportive Documentation Recommendations
These codes are typically consultative. It is expected that the administration of these tests will generate material that will be formulated into a report. That report should clearly indicate the purpose and rationale for the test, the test performed with results and how the information affects the treatment plan.
Application of Casts and Strapping Codes
The casting and strapping procedures apply when the cast application or strapping is a replacement procedure used during or after the period of follow-up care, or when the cast application or strapping is an initial service performed without a restorative treatment or procedure(s) to stabilize or protect a fracture, injury, or dislocation and/or to afford comfort to a patient.

A physician who applies the initial cast, strap or splint and also assumes all of the subsequent fracture, dislocation, or injury care cannot use the application of casts and strapping codes as an initial service, since the first cast/splint or strap application is included in the treatment of fracture and/or dislocation codes. A temporary cast/splint/strap is not considered to be part of the preoperative care.

General Guidelines for Casting
Therapists typically do not utilize casting interventions for the treatment of fractures. However, casting techniques used by therapists for positioning and stretching are a covered service when an improvement can be noted in an individual’s movement patterns and skills. For example, a spastic hand can be casted to facilitate relaxation of the fingers. Serial casting can be essential for individuals with traumatic brain injury- induced spasticity, CVA, and other conditions. Casting should not be utilized for basic contracture management issues. Casting goals should objectively indicate expectation of progress, whereas, the main function of contracture management is to decrease the risk of further contracture.
More than 8-10 visits for evaluation, treatment, modification and caregiver education would not be considered reasonable and necessary without significant documentation.
These are untimed codes.
General Guidelines for Strapping


Strapping refers to the application of overlapping strips of adhesive plaster or tape to a body part to exert pressure and hold a structure in place. Strapping may be used to treat strains, sprains, dislocations, and some fractures. The strapping codes are intended to be used when the desired effect is to provide total immobilization or restriction of movement. These services are typically performed outside a therapy plan of care.
Strapping is not always synonymous with taping (such as McConnell taping or kinesiotaping). See additional information on taping under therapeutic procedures. See the code for wrapping techniques for manual lymphatic drainage.
For dates of service on and after 10/1/2010, low back strapping (regardless of CPT code billed) will be considered a non-reimbursable service under Medicare, as the service has been removed from CPT as an obsolete procedure [CPT Changes 2010 – An Insider’s View, page 91].
Special instructions for – Strapping; Unna boot
The application of Unna boot paste (zinc, gelatin, or other product) as a bandage or “colloid” dressing, is applied to an extremity for the treatment of dermatological, vascular, and on occasion, other conditions. These dressings are often covered by an elastic bandage to give added support, hold the dressing in place and provide a protective cover. Unna boot application is appropriate in the treatment of ulcerations with and without inflammation due to stasis dermatitis produced by vascular insufficiency. The Unna boot is also appropriate for treating ligamentous injuries (sprains and strains) of the ankle. Unna boots need to be changed on a regular basis, depending on the exact type used and the indication. Bilateral unna boots should be billed with a modifier -50 (bilateral procedure).
These are untimed codes.
Unlisted procedure, casting or strapping
If an existing CPT code does not describe the service performed, an unlisted CPT code may be used. The use of unlisted codes should be rare. If unlisted codes are billed, the medical record and claim must clearly state what modality or procedure is billed as an unlisted code. If not, the unlisted code billed will be subject to denial for insufficient information. As of 10/01/2010, low back strapping  should not be billed with unlisted procedure, casting or strapping.

Supportive Documentation Recommendations unlisted procedure, casting or strapping
This is an untimed code, billable as "1" unit.
Please see section Documentation Recommendations for Unlisted Procedure Codes.
Please see the Unlisted Procedure Codes section of article A49932, Outpatient Physical and Occupational Therapy Services - Supplemental Instructions Article, for specific billing instructions.
General Guidelines for Splinting
According to CPT Assistant-February 2007, orthosis application differs from the purpose of an application of a cast or strapping device. Casting and strapping codes should not be reported for orthotics fitting and training.
Splinting codes, though rarely used by therapists, may be appropriate for clinical situations (e.g., fracture, sprain, dislocation) where temporary immobilization/fixation is required until there is further treatment disposition.
This example is based upon a clinical vignette in CPT Assistant-April 2002. Patient C is a 70-year-old female who presents to the outpatient orthopedic clinic following a left ankle injury when her foot became twisted in her dog's run chain. After the orthopedist evaluates the patient, radiologic views were obtained that substantiated the diagnosis of a sprained ankle ligament. A short-leg plaster posterior molded splint is applied by the physical therapist due to the degree of swelling. Upon return to the orthopedic clinic, the splint is removed, x-rays repeated, and based on those findings, a short-leg fiberglass non-walking cast is applied.
These are untimed codes.

 Biofeedback training by any modality
 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry

Biofeedback therapy provides visual, auditory or other evidence of the status of certain body functions so that a person can exert voluntary control over the functions, and thereby alleviate an abnormal bodily condition. Biofeedback therapy often uses electrical devices to transform bodily signals indicative of such functions as heart rate, blood pressure, skin temperature, salivation, peripheral vasomotor activity, and gross muscle tone into a tone or light, the loudness or brightness of which shows the extent of activity in the function being measured.
Biofeedback therapy differs from electromyography which is a diagnostic procedure used to record and study the electrical properties of skeletal muscle. An electromyography device may be used to provide feedback with certain types of biofeedback.
Biofeedback therapy is covered under Medicare only when it is reasonable and necessary for the individual patient for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments (heat, cold, massage, exercise, support) have not been successful. This therapy is not covered for treatment of ordinary muscle tension states or for psychosomatic conditions
. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 30.1)
Biofeedback for incontinence
Biofeedback 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 is not a treatment, per se, but a tool to help patients learn how to perform PME. 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.
A failed trial of PME training is defined as no clinically significant improvement in urinary incontinence after completing four weeks of an ordered plan of pelvic muscle exercises to increase periurethral muscle strength.


Medicare will allow biofeedback as an initial incontinence treatment modality only when, in the opinion of the physician, that approach is most appropriate and there is documentation of medical justification and rationale for why a PME trial was not attempted first.

Patient selection is a major part of the process and the patient should be motivated, cognitively intact, and compliant. In addition, there must be assurance that the pelvic floor musculature is intact. Biofeedback therapy has proven successful for urinary incontinence when all three of the following conditions exist:

  • the patient is capable of participation in the plan of care;
  • the patient is motivated to actively participate in the plan of care, including being responsive to the care requirements (e.g., practice and follow-through by self or caregiver); and
  • the patient's condition is appropriately treated with biofeedback (e.g., pathology does not exist preventing success of treatment).


When providing biofeedback procedures for urinary incontinence, use the appropriate CPT code when EMG and/or manometry are not performed.
Biofeedback that is more involved than conventional biofeedback measures  and includes evaluations of the EMG activity of the pelvic muscles, urinary sphincter and/or anal sphincter by using sensors. This procedure can use manometry (measure of pressure of gases or liquids by use of a manometer) or EMG (electromyography - the recording of electrical activity initiated in the muscle tissue for testing purposes) to measure activity. The EMG activity is evaluated and provides objective information regarding the muscle activity and provides a basis for pelvic muscle rehabilitation utilizing biofeedback.
Biofeedback is non-covered for:

  • home use of biofeedback therapy;
  • pelvic floor electrical stimulation lacking documentation of the failure of a trial of pelvic muscle exercise (PME) training, unless there is physician documentation justifying the need to initiate treatment with biofeedback before PME is attempted;
  • patients who do not have sufficient cognitive ability to adhere to and follow the PME protocol and/or cooperate in keeping a personal voiding diary.


Patients not showing improvement after 5-6 visits of retraining with biofeedback are not likely to improve with additional sessions. Additional documentation is necessary to justify biofeedback services beyond 5-6 visits.
The descriptor for the biofeedback codes does not include a time element; therefore, these codes should be billed as one (1) unit.

Supportive Documentation Recommendations for biofeedback
As noted in the NCD descriptions above, biofeedback is covered only when more conventional treatments such as heat, cold, massage, exercise (such as PME), and/or support have not been successful. Therefore, documentation must provide a clear history of the conventional treatments unsuccessfully tried before initiating biofeedback. Since biofeedback is only covered when there is a lack of response to other therapies, the lack of response to or contraindication to, other therapies must be noted in the patient's record.
Additionally for the treatment of incontinence, include:

  • identification of the type and degree of incontinence, expectations from the treatment and the time frame in which an improvement is anticipated;
  • clear documentation of the formal instruction, monitoring and follow-up of a prescribed course of PME;
  • evidence of behavioral modification training including, but not limited to, bladder retraining and fluid intake modification;
  • the use of a patient record-keeping system, such as a personal voiding diary, in evaluating and monitoring progress.


Standardized cognitive performance testing (e.g., Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report.


According to CPT 2008 Changes, An Insider’s View, patients who have compromised functioning abilities due to acute neurological events such as TBI or CVA must undergo assessment to determine if abilities such as orientation, memory and high-level language function have been comprised and to what extent. Health care professionals such as speech-language pathologists (SLPs) and OTs perform a battery of test procedures called standardized cognitive performance testing in order to make these important determinations. These tests evaluate different aspects of neurocognitive function including memory (short-term, long-term, and organizational), reasoning, sensory processing, visual perceptual status, orientation, right hemisphere processing for temporal and spatial organization, social pragmatics, and elements of decision- making and executive function.

A code has been established to report these test procedures when performed by qualified health care professionals, such as SLPs and OTs. This is a time-based code intended to be reported per hour, including the time administering the tests to the patient, interpreting the results, and preparing the report. Note that this code includes both face-to-face time and non-face-to-face time.


Clinical example:
A 36 year old male with Traumatic Brain Injury from a motor vehicle accident is referred to the health care professional for standardized cognitive performance testing following a recent discharge. The qualified health care professional selects and completes face-to- face administration of the appropriate standardized test(s) to examine the patient’s current level of functional cognitive performance. Raw and standardized scores are derived and analyzed. A written report is prepared by the qualified health care professional and sent to the referring physician.
Miscellaneous Services (Non-covered)
The following are non-covered as skilled therapy services. This is not an all inclusive list.

    • Iontophoresis, except as indicated for primary focal hyperhidrosis
    • Anodyne
    • Low level laser treatment (LLLT)/cold laser therapy
    • Dry hydrotherapy massage (e.g., aquamassage, hydromassage, or water massage)
    • Massage chairs or roller beds
    • Interactive metronome therapy
    • Loop reflex training
    • Vestibular ocular reflex training
    • Continuous passive motion (CPM) device setup and adjustments
    • Craniosacral therapy
    • Electro-magnetic therapy, except as indicated for chronic wounds
    • Constraint Induced Movement Therapy (CIMT)
    • Driving assessments
    • Work-hardening programs
    • Pelvic Floor Dysfunction (not including incontinence)
      • Due to the lack of peer reviewed evidence concerning the effect on patient health outcomes, skilled therapy interventions (e.g., ultrasound, electrical stimulation, soft tissue mobilization, and therapeutic exercise) for the treatment of the following conditions is considered investigational and thus non-covered.
        • pelvic floor congestion
        • pelvic floor pain not of spinal origin
        • hypersensitive clitoris
        • prostatitis
        • cystourethrocele
        • enterocele
        • rectocele
        • vulvodynia
        • vulvar vestibulitis syndrome (VVS)

 

  • Functional Electrical Stimulating (FES) devices other than those that assist in walking are not covered under Medicare [NCD 160.12]. Consequently, any services related to the evaluation for or training of patients to use such a device is not covered. Such devices may include, but are not limited, to the Ergys® system.



Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

General Information

Associated Information
N/A
Sources of Information

This bibliography presents those sources that were obtained during the development of this policy. CGS Administrators, LLC is not responsible for the continuing viability of Web site addresses listed below.

FDA Safety Communication:UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems dated 24 February 2011:
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm


Akinbo SR, Aiyejusunle CB, Akinyemi OA, Adesegun SA, Danesi MA. Comparison of the therapeutic efficacy of phonophoresis and iontophoresis using dexamethasone sodium phosphate in the management of patients with knee osteoarthritis. Nigerian Postgraduate Medical Journal. 2007;14(3):190-4.

American Medical Association, CPT 2008 – Professional Edition.

American Medical Association, CPT Assistant.

American Medical Association, CPT Changes – An Insider’s View, Chicago IL.

American Occupational Therapy Association, www.aota.org, last accessed April 2008.

American Physical Therapy Association, www.apta.org, last accessed April 2008.

Barker RN, Brauer SG, Carson RG. Training of reaching in stroke survivors with severe and chronic upper limb paresis using a novel nonrobotic device: a randomized clinical trial. Stroke. June 2008;1800-1807.

Baskurt F, Ozcan A, Algun C. Comparison of effects of phonophoresis and iontophoresis of naproxen in the treatment of lateral epicondylitis. Clin Rehabil. 2003;17(1):96-100.

Bertolucci LE. Introduction of antiinflammatory drugs by iontophoresis: double blind study. J Orthop Sports Phys Ther. 1982;4(2):103-108.

Brown KE, Whitney SL, Wrisley DM, Furman JM. Physical therapy outcomes for persons with bilateral vestibular loss. Laryngoscope. 2001;111(10):1812-7.

Chan MK, Tong RK, Chung KY. Bilateral upper limb training with functional electrical stimulation in patients with chronic stroke. Neurorehabilitation and Neural Repair. 2009;23(4):357-365.

Chaturvedula A, Joshi DP, Anderson C, Morris R, Sembrowich WL, Banga AK. Iontophoresis. Pharmaceutical Research [NLM - MEDLINE]. 2005;22(8):1313.

Coding and Payment Guide for the Physical Therapist, American Physical Therapy Association. Salt Lake City, UT. Ingenix. St. Anthony Publishing/Medicode. 10th Edition. 2003.

Comparison of the effects of tens and sodium salicylate iontophoresis in the management of osteoarthritis of the knee. Nigerian Quarterly Journal of Hospital Medicine. 2007;17(1):30-4.

Crawford F, Thomson C. Interventions for treating plantar heel pain. The Cochrane Library, The Cochrane Collaboration, Copyright 2007;4.

Curdy C, Kalia YN, Naik A, Guy RH. Piroxicam delivery into human stratum corneum in vivo: iontophoresis versus passive diffusion. Journal of Controlled Release. 2001;76(1):73-79.

Demirtas RN, Oner C. The treatment of lateral epicondylitis by iontophoresis of sodium salicylate and sodium diclofenac. Clin Rehabil. 1998;12(1):23-9.

Ennis W, Formann P, Mozen N, Massey J, Conner-Kerr T, Meneses P. Ultrasound therapy for recalcitrant diabetic foot ulcers: results of a randomized, double-blind, controlled, multicenter study, MIST ultrasound diabetic foot study group. Ostomy/Wound Management. 2005;51(8):24-39.

Enticott JC, O’Leary S, Briggs RJ. Effects of vestibule-ocular reflex exercises on vestibular compensation after vestibular schwannoma surgery. Otol Neurotol. 2005;26(2):265-9.

Gudeman SD, Eisele SA, Heidt RS, Colosimo AJ, Stroupe AL. Treatment of plantar fasciitis by iontophoresis of 0.4% dexamethasone: a randomized, double-blind, placebo-controlled study. Am J Sports Med. 1997;25(3):312-6,(30 ref).

Guide to Physical Therapist Practice, American Physical Therapy Association, Second Edition, Alexandria, VA, Phys Ther. 2001;81:9-744, Revised 2003.

Handy J, Salinas S, Blanchard SA, Aitken MJ. Meta-analysis examining the effectiveness of electrical stimulation in improving functional use of the upper limb in stroke patients. Physical & Occupational Therapy in Geriatrics. 2003;21(4):67-78.

Hara Y. Neurorehabilitation with new functional electrical stimulation for hemiparetic upper extremity in stroke patients. J Nippon Med Sch. 2008;75(1):4-14.

Hedman LD, Sullivan JE, Hilliard MJ, Brown DM. Neuromuscular electrical stimulation during task-oriented exercises improves arm function for an individual with proximal arm dysfunction after stroke. Am. J. Phys. Med. Rehabil. 2007;86(7):592-596.

Japour CJ, Vohra R, Vohra PK, Garfunkel L, Chin N. Management of heel pain syndrome with acetic acid iontophoresis. J Am Podiatr Med Assoc. 1999;89(5):251-7.

Kavros, S., Miller, J., Hanna, S., Treatment of ischemic wounds with noncontact, low-frequency ultrasound: the Mayo Clinic experience, 2004-2006, Advances in Skin & Wound Care. 2007;20:221-226.

Kavros S, Schenck. Use of noncontact low-frequency ultrasound in the treatment of chronic foot and leg ulcerations: a 51-patient analysis. Journal of the American Podiatric Medical Association. 2007;97(2).

Khan F. Iontophoresis. Medical Devices & Surgical Technology Week. Atlanta: Oct 31, 2004:110.

Lai J, Pittelkow M. Physiological effects of ultrasound mist on fibroblasts. International Journal of Dermatology. 2007;46:587-593.

Leduc BE, Caya J, Tremblay S, Bureau NJ, Dumont M. Treatment of calcifying tendinitis of the shoulder by acetic acid iontophoresis: a double-blind randomized controlled trial. Arch Phys Med Rehabil. 2003;84(10):1523-7.

Li LC, Scudds RA, Heck CS, Harth M. The efficacy of dexamethasone iontophoresis for the treatment of rheumatoid arthritic knees: a pilot study. Arthritis Care Res . 1996;9(2):126-32.

Neeter C, Thomee R, Silbernagel KG, Thomee P, Karlsson J. Iontophoresis with or without dexamethazone in the treatment of acute Achilles tendon pain. Scand. J. Med Sci Sport. 2003;13:376-382.

Nirschl RP, Rodin DM, Ochiai, DH, Maartmann-Moe C. Iontophoretic administration of dexamethasone sodium phosphate for acute epicondylitis. Am J. Sport Med. 2003;31(2):189-195.

Osborne HR, Allison GT. Treatment of plantar fasciitis by LowDye taping and iontophoresis: short term results of a double blinded, randomized, placebo controlled clinical trial of dexamethasone and acetic acid. Br. J. Sports Med. 2006;40:545-549.

Other Contractors’ LCDs.

Page SJ, Maslyn S, Hermann VH, Wu A, Dunning K, Levine PG. Activity-based electrical stimulation training in a stroke patient with minimal movement in the paretic upper extremity. Neurorehabilitation and Neural Repair. 2009;23(6):595-599.

Pellecchia GL, Hamel H, Behnke P. Treatment of infrapatellar tendinitis: a combination of modalities and transverse friction massage versus iontophoresis. J Sport Rehabil. 1994;3(2):135-145.

Perron M, Malouin F. Acetic acid iontophoresis and ultrasound for the treatment of calcifying tendinitis of the shoulder: a randomized control trial. Arch Phys Med Rehabil. 1997;78(4):379-84.

Thawer H, Houghton P. Effects of ultrasound delivered through a mist of saline to wounds in mice with diabetes mellitus. Journal of Wound Care. 2004;13(5).

von Lewinski F, Hofer S, Kaus J, et al. Efficacy of EMG-triggered electrical arm stimulation in chronic hemiparetic stroke patients. Restor Neurol Neurosci. 2009;27(3):189-197.

Wasner G, Kleinert A, Binder A, Schattschneider J, Baron R. Baron R, Iontophoresis. Journal of Neurology. 2005;252(6):677.

Wieder DL. Treatment of traumatic myositis ossificans with acetic acid iontophoresis. Phys Ther. 1992;72(2):133-7.

Yarrobino TE, Kalbfleisch JH, Ferslew KE, Panus PC. Lidocaine iontophoresis mediates analgesia in lateral epicondylalgia treatment. Physiotherapy Research International. 2006;11(3):152-60.

Bibliography

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Revision History Information

Revision History DateRevision History NumberRevision History ExplanationReasons for Change
05/27/2021 R16

R17

Revision Effective: 05/27/2021

Revision Explanation: Annual Review, correction to typo under Coverage Indications, Limitations and/or Medical Necessity.

5/17/2021: 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; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
11/14/2019 R15

R16

Revision Effective: N/A

Revision Explanation: Annual Review, no changes made 

5/27/2020: 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; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual review)
11/14/2019 R14

R15

Revision Effective: 11/14/2019

Revision Explanation: Removed other comments section from coverage and indications section and the associated information section from policy and placed in the related billing and coding article. In revision 10 and 11 G0151 should have been G0515. 

09/13/2019: 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; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Provider Education/Guidance
09/19/2019 R13

R134

Revision Effective: 09/19/2019

Revision Explanation: REeoved all coding from policy and placed into a related billing and coding article. Based on CR 10901

09/13/2019: 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; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Code Migration)
01/01/2018 R12

R13 

Revision Effective: N/A

Revision Explanation: Annual review no changes made.

May 28, 2019: 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; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Other (Annual Review)
01/01/2018 R11

 

R12

 

Revision Effective:N/A

 

Revision Explanation: Annual review no changes made.

 

 

 

DATE (05/31/2018): 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; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

  • Other (Annual review)
01/01/2018 R10

Revision#: R11
Revision Effective: 01/01/2018
Revision Explanation: In associated section next to last paragraph retired code 97532 and 97762 were left in error. Corrected and added new codes that replaced during annual HCPCS update. 97532 and 97762 were end dated 12/31/2017. 97763 replaces 97762 and G0151 replaces 97532 effective 01/01/2018

02/06/2018-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; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

  • Typographical Error
01/01/2018 R9

Revision#: R10
Revision Effective: 01/01/2018
Revision Explanation: Annual HCPCS update 97532 and 97762 were end dated 12/31/2017. 97763 replaces 97762 and G0151 replaces 97532 effective 01/01/2018

12/18/2017-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; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

 

Revision#: R9
Revision Effective: N/A
Revision Explanation: Annual review no changes made.

  • Revisions Due To CPT/HCPCS Code Changes
01/01/2017 R8 Revision#: R8
Revision Effective: 01/01/2017
Revision Explanation: Removed bill type 034X as it is not appropriate for this policy.
  • Other (Bill Type included in error)
01/01/2017 R7 Revision#: R7
Revision Effective: 01/01/2017
Revision Explanation: CPT codes 97011-97004 replaced with new codes 97161-97168 during annual HCPCS update.
  • Revisions Due To CPT/HCPCS Code Changes
07/01/2016 R6 Revision#: R6
Revision Effective: 07/01/2016
Revision Explanation: Added clarifying language to the policy concerning patient need of skilled care.
  • Provider Education/Guidance
10/01/2015 R5 Revision#: R5
Revision Effective: 10/01/2015
Revision Explanation: added the following ICd-10 codes effective 10/01/2015:
N39.3
N39.41
N39.42
N39.43
N39.46
N39.490
R15.0
R15.1
R15.2
R15.9
R33.8
R35.0

  • Reconsideration Request
10/01/2015 R4 Revision#: R4
Revision Effective: 10/01/2015
Revision Explanation: Accepted description changes made by administrator with update in May.
  • Other (description changes for bill type codes 034 accepted)
10/01/2015 R3 Revision#: R3
Revision Effective: 10/01/2015
Revision Explanation: Added new CPT codes 97607 and 97608.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R2 Revision#: R1
Revision Effective: 10/01/2015
Revision Explanation: Accepted 2015 code description changes for 97605 97606.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R1 Revision#: R1
Revision Effective: N/A
Revision Explanation: Attached the outpatient phyiscal therapy fact sheet.
  • Provider Education/Guidance

Associated Documents

Attachments
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Related National Coverage Documents
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Public Versions
Updated On Effective Dates Status
05/26/2022 06/02/2022 - N/A Currently in Effect View
05/17/2021 05/27/2021 - 06/01/2022 Superseded You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

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