Local Coverage Determination (LCD)

Outpatient Physical Therapy

L34428

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

Document Note

Note History

Contractor Information

LCD Information

Document Information

Source LCD ID
N/A
LCD ID
L34428
Original ICD-9 LCD ID
Not Applicable
LCD Title
Outpatient Physical Therapy
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 05/18/2023
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A

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Issue

Issue Description

This LCD outlines limited coverage for this service with specific details under Coverage Indications, Limitations and/or Medical Necessity.

Issue - Explanation of Change Between Proposed LCD and Final LCD

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1862(a)(1)(A) allows coverage and payment for only those services that are considered to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member

Title XVIII of the Social Security Act, §1862(a)(7) excludes routine physical examinations

42 CFR §409.32 Criteria for skilled services and the need for skilled services

42 CFR §410.32(b)(3) Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests: Conditions

42 CFR §410.61 Plan of treatment requirements for outpatient rehabilitation services

42 CFR §424.24 Requirements for medical and other health services furnished by providers under Medicare Part B

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 6, §20.5.2 Coverage of Outpatient Therapeutic Services Incident to a Physician’s Service Furnished on January 1, 2010 through December 31, 2019

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 8, §30.2.2.1 Documentation to Support Skilled Care Determinations, §30.4.1.1 General, §30.4.1.2 Application of Guidelines and §30.6 Daily Skilled Services Defined

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, §10 Comprehensive Outpatient Rehabilitation Facility (CORF) Services Provided By Medicare, §20.1 Required Services, §20.2 Optional CORF Services, §40.1 Physician’s Services, §40.2 Physical Therapy Services and §40.7 Social and/or Psychological Services

CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance, §220.1.1 Care of a Physician/Nonphysician Practitioner (NPP), §220.1.2 Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services, §220.1.3 Certification and Recertification of Need for Treatment and Therapy Plans of Care, §220.1.4 Requirement That Services Be Furnished on an Outpatient Basis, §220.2 Reasonable and Necessary Outpatient Rehabilitation Therapy Services, §220.3 Documentation Requirements for Therapy Services, §230 Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology, §230.1 Practice of Physical Therapy, §230.4 Services Furnished by a Therapist in Private Practice (TPP), §230.5 Physical Therapy, Occupational Therapy and Speech-Language Pathology Services Provided Incident to the Services of Physicians and Non-Physician Practitioners (NPP)

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §10.2 Transcutaneous Electrical Nerve Stimulation (TENS) for Acute Post-Operative Pain, §30.1 Biofeedback Therapy, §30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.5 Diathermy Treatment, §150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders, §160.2 Treatment of Motor Function Disorders with Electric Nerve Stimulation, §160.7 Electrical Nerve Stimulators, §160.12 Neuromuscular Electrical Stimulator (NMES), §160.15 Electrotherapy for Treatment of Facial Nerve Palsy (Bell’s Palsy), §160.27 Transcutaneous Electrical Nerve Stimulation (TENS) for Chronic Low Back Pain (CLBP)

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.1 Institutional and Home Care Patient Education Programs

CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §240.3 Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions, §240.8 Pulmonary Rehabilitation Services, §270.1 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds, §270.4 Treatment of Decubitus Ulcers, §270.6 Infrared Therapy Devices

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Although there is an overlap in services provided by physical and occupational therapists, this policy addresses only physical therapy (PT).

PT services are part of a constellation of rehabilitative services designed to improve or restore physical functioning, as well as, to prevent injury, impairments, activity limitations, participation restrictions and disability following disease, injury or loss of a body part. Impairments, activity limitations and disabilities are addressed by the examination, evaluation and development of a plan of care (POC) that may include implementation of therapeutic interventions tailored to the specific needs of the individual patient to achieve specific goals and outcomes. The specific interventions that may be utilized are therapeutic exercises to strengthen muscles, maintain or restore motion, integumentary repair and protection techniques, physical agents and mechanical modalities, such as heat, cold, electrotherapeutic modalities, ultrasound (US) and hydrotherapy, manual therapy and functional training or retraining an individual to perform the activities of daily living (ADLs).

All PT services must be performed by or under the supervision of a qualified physical therapist.

For the purposes of this Local Coverage Determination (LCD), the descriptions/definitions of supervision are those given in 42 CFR §410.32(b)(3).

Qualified Physical Therapist: An individual who is licensed as a physical therapist and meets the practice requirements in the state where they are practicing.

For outpatient settings, references to “physicians” throughout this policy include nonphysician practitioners (NPPs), such as nurse practitioners, clinical nurse specialists and physician assistants. Such NPPs may certify, order and establish the POC for services by physical therapists as authorized by state law.

A qualified physical therapist, for program coverage purposes, is defined as an individual who is licensed as a physical therapist and meets the practice requirements in the state where they are practicing. Physiatrists, physicians or NPPs, and qualified physical therapists have the knowledge, training, and experience required to evaluate and, as necessary, re-evaluate a patient’s level of function, and determine whether a PT program could reasonably be expected to improve, restore or compensate for lost function. Where appropriate, the physical therapist can recommend to the physician or NPP a POC. While the skills of a qualified physical therapist are required to evaluate the patient’s level of function and develop a POC, implementation of the plan may also be carried out by a qualified physical therapy assistant (PTA) functioning under the general supervision of the qualified physical therapist. 

Some services must be provided by a licensed therapist and may not be performed by a PTA such services include:

  • Making clinical judgements or decisions
  • Developing, managing or furnishing skilled maintenance programs
  • Supervising other clinicians or taking responsibility for the service rendered
  • Acting outside of the directions and supervision of a treating therapist in accordance with state laws

Restorative/Rehabilitative therapy:

In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services. 

Maintenance therapy:

A maintenance program is a program designed to maintain or to slow deterioration as described in the CMS Internet-Only Manual Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220 and §220.2 and must meet these criteria to be considered reasonable and necessary.

GENERAL PT GUIDELINES

1. PT services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed physical therapist or under his/her supervision. Services normally considered a routine part of nursing care are not covered as PT (i.e., turning patients to prevent pressure injuries, walking a patient in the hallway postoperatively or ambulation without gait training).

2. Covered PT must be furnished while the individual is or was under the care of a physician. Services must relate directly and specifically to a written plan of treatment regimen established by the physician or NPP after any necessary consultation with the qualified physical therapist, or by the physical therapist providing the services and must be reasonable and necessary to the treatment of the individual's illness or injury.

3. In order for the plan of treatment to be covered, it must address a condition for which PT is an accepted method of treatment as defined by standards of medical practice. Also, the plan of treatment must be for a condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer be considered reasonable and necessary and are excluded from coverage.

4. PT is only covered when it is rendered under a written plan of treatment established by the physician, NPP or the qualified physical therapist, to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or NPP should periodically review the plan of treatment.

5. The physician or NPP and/or therapist must document the patient's functional limitations in terms that are objective and measurable. 

SPECIFIC PROCEDURE AND MODALITY GUIDELINES

Computerized Dynamic Posturography

Computerized dynamic posturography is a "quantitative method for assessing balance functioning under various simulated tasks. Protocols are designed to test the sensory, motor and biomechanical components of balance individually and in concert." Computerized dynamic posturography "may assist with lesion localization, identifying adaptive strategies and functional capabilities."

*Note: Results of computerized dynamic posturography must be used in determining the patient centered POC.

Wound Care Selective 

a) Debridement:

Debridement is indicated whenever necrotic tissue is present on a documented open wound. Debridement may also be indicated in cases of abnormal wound repair.

b) Conservative Sharp Debridement:

Conservative sharp debridement is a minor procedure that requires no anesthesia and is performed on an outpatient basis. Scalpel, scissors, and forceps may be used and only clearly identified devitalized tissue is removed. Generally, there is no specific bleeding associated with this procedure.

Wound(s) Care Non-Selective Debridement and Negative Pressure Wound Therapy 

a) Enzymatic Debridement:

Debridement with topical enzymes is used when necrotic substances to be removed from a wound are protein, fibrin and collagen. The manufacturer's product insert contains indications, contraindications, precautions, dosage, and administration. It would be the clinician's responsibility to comply with the product insert/guidelines.

b) Autolytic Debridement:

This type of debridement is indicated where manageable amounts of necrotic tissue are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found in wound fluids are sequestered under synthetic dressings. Autolytic debridement is contraindicated for wounds that contain infection.

c) Mechanical Debridement:

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.

Hydrotherapy and wound irrigation are also forms of mechanical debridement used to remove necrotic tissue. They also should be used cautiously, as maceration of surrounding tissue may hinder healing.

d) Negative Pressure Wound Therapy:

Negative Pressure Wound Therapy is a non-invasive treatment by which controlled localized negative pressure is delivered to a wide variety of acute, sub-acute, and chronic wounds. Negative Pressure Wound Therapy should be used cautiously as maceration of surrounding tissue may hinder healing.

Fabrication/Application of Casts, Splints and Strapping

Fabrication and application of casts, splints, and strapping (e.g., the use of elastic wraps, heavy cloth, adhesive tape) will be considered reasonable and necessary if used to support weak or ineffective joints/muscles, reduce/correct joint limitations/deformities and/or protect body parts from injury, thus enhancing the performance of tasks or movements. The casts, splints and strapping are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of patient needs and social/culture environments.

BODY AND UPPER EXTREMITY CASTS

Application of long arm cast

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures and/or other deformities involving soft tissue.

Application of short arm cast

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Application of hand and lower forearm cast

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

SPLINTS

Application of long arm splint

May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Application of short arm splint

May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

Application of finger splint

May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.

STRAPPING-ANY AGE

Strapping of thorax

May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of low back 

May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of shoulder (e.g., Velpeau)

May be indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of elbow or wrist 

May be indicated for the elbow or wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

Strapping of hand or finger

May be indicated when there is involvement of the hand or finger(s) in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissue.

LOWER EXTREMITY CASTS

Application of long leg cast

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg cast

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of rigid leg cast

May be indicated for recent amputees or patients with lower extremity ulcers.

SPLINTS

Application of long leg splint

May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

Application of short leg splint

May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

STRAPPING-ANY AGE

Strapping of hip

May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of knee

May be indicated when there is involvement of the thigh, knee, or lower leg in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of ankle and/or foot

May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Strapping of toes

May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

Application of unna boot

A dressing for ulcers resulting from venous insufficiency, consisting of a paste made from gelatin zinc oxide and glycerin, which is applied to the leg, then covered with a spiral bandage, this in turn being given a coat of the paste. The process is repeated until satisfactory rigidity is attained.

Biofeedback training any method and biofeedback training perineal muscles, anorectal or urethral sphincter including EMG and/or manometry 

The coverage criteria and definition of biofeedback therapy is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.1 and §30.1.1.

"Biofeedback is a tool utilized by physical therapists to assist with muscle training. This includes facilitation of muscles that are demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can be visual or auditory."

Muscle testing, manual

Manual testing of muscle groups for strength are based on grading scales.

Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk 

Every muscle of at least 1 extremity would need to be tested, with documentation of why such a thorough assessment was warranted.

Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side 

Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands or including hands

The measurement of muscle performance using manual muscle testing only.

Range of Motion (ROM) Measurements

Determination of ROM using a tape measure, flexible ruler, electronic device or goniometer.

Every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted.

PT Evaluation

Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted, e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the POC, including goals and the selection of interventions. The time spent in evaluation does not count as treatment time.

1. The initial examination has the following components:

 a. The patient history to include prior level of function

 b. Relevant systems reviews

 c. Tests and measures

 d. Current functional status (abilities and deficits) 

2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent of loss of function, social considerations, and the patient's overall physical function and health status. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Physical therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, disability, the living environment, and the social supports.

3. Initial evaluations or re-evaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized.

4. Re-evaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient's condition or functional status. Some regulations and state practice acts require re-evaluation at specific intervals. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services.

5. A re-evaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.

MAINTENANCE PROGRAMS

A maintenance program is a program intended to maintain function or slow the decline in function. Coverage of skilled rehabilitation services is contingent upon a beneficiary's need for skilled care. When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively, provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient's unique circumstance. The provision of therapy services by skilled personnel does not in itself make the service one that requires skilled care.
 
Hot or Cold Packs Therapy

Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm and reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs are used for subacute or chronic painful conditions.

Mechanical Traction Therapy

1. Traction is generally limited to the cervical or lumbar spine with the hope of relieving pain in or originating from those areas.

2. Specific indications for the use of mechanical traction include:

 a. Cervical and/or lumbar radiculopathy

 b. Back disorders, such as disc herniation, lumbago, and sciatica

Vasopneumatic Device Therapy

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

2. Specific indications for the use of vasopneumatic devices include:

a. Reduction of edema after acute injury

b. Lymphedema of an extremity

c. Education and training on the use of vasopneumatic devices for home use

Note: Further treatment on the use of vasopneumatic devices by physical therapists, after the education and training visits, is usually not reasonable and necessary. Generally, education and training can be completed in 3 visits.

Paraffin Bath Therapy

1. Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands, and feet.

2. Heat treatments of this type do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.

Whirlpool Therapy/Hubbard Tank

1. Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.

2. Whirlpool bath and Hubbard Tanks are the most common forms of hydrotherapy. The use of whirlpool is considered reasonable and necessary when used as part of a plan directed at facilitating the healing of an open wound (e.g., burns).

3. Specific indications for the use of whirlpools include the following:

a. The patient having a documented open wound which is draining, has a foul odor, or evidence of necrotic tissue

b. The patient having a documented need for wound debridement/bandage removal

c. Exfoliative skin impairments

Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders (Dry Whirlpool)

The coverage criteria and definition of fluidized therapy dry heat (dry whirlpool) are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.8.

Diathermy Treatment

Diathermy coverage criteria and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.5 and Part 4, §240.3.

Infrared Therapy Devices

Noncoverage of Infrared Therapy Devices is described in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.6.

Ultraviolet Therapy

The application of ultraviolet therapy is considered reasonable and necessary for the patient requiring the application of a drying heat. The specific indications for this therapy are as follows:

a. A patient having an open wound; minimal erythema

b. Severe psoriasis limiting ROM

Electrical Stimulation Therapy

"Visual, verbal and/or manual contact "(i.e., constant attendance) when 1-on-1 instruction is required for subsequent home use of a Transcutaneous Electrical Nerve Stimulation (TENS) unit.

TENS is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under §1862(a)(1)(A) of the Social Security Act.

Electrical Stimulation (ES) Therapy-Unattended

Electrical stimulation therapy and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.1.

Electromagnetic Therapy

Electromagnetic therapy criteria and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.1.

Iontophoresis Application

1. Iontophoresis is a process in which electrically charged molecules or atoms (i.e., ions) are driven into tissue with an electrical field. Voltage provides the driving force. Parameters such as, drug polarity and electrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites below the skin.

2. The application of iontophoresis is considered reasonable and necessary for the topical delivery of medications into a specific area of the body.

3. Specific indications for the use of iontophoresis application include:

a. The patient having tendonitis or calcific tendonitis

b. The patient having bursitis

c. The patient having adhesive capsulitis

d. The patient having hyperhidrosis

e. Thick adhesive scar(s) 

Contrast Baths

1. Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications are possible, contrast baths often are used in treatment to decrease edema and inflammation.

2. The use of contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.

3. Specific indications for the use of contrast baths include:

a. The patient having rheumatoid arthritis or other inflammatory arthritis

b. The patient having reflex sympathetic dystrophy

c. The patient having a sprain or strain resulting from an acute injury

4. Heat treatments of this type and contrast baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications. Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.

US

1. Therapeutic US is a deep heating modality that produces a sound wave of 0.8 to 3.0 MHz. In the human body, US has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of US, as much as 30% more. Because of the increased extensibility US produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted ROM.

2. The application of US is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.

3. Specific indications for the use of US application include:

a. The patient having tightened structures limiting joint motion that require an increase in extensibility

b. The patient having symptomatic soft tissue calcification

c. The patient having neuromas

Note: US application is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.

GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES

1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services.

2. Use of these procedures requires that these services be rendered under the supervision of a physical therapist.

3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented in the written plan of treatment, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any 1 or a combination of more than 1 of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

4. Services provided concurrently by a physical therapist and occupational therapist may be covered, if separate and distinct goals are documented in the written plan of treatment.

5. Require 1-on-1 direct patient contact, unless otherwise stated. 

Therapeutic Exercises

1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening, continuous passive motion).

2. Therapeutic exercise may address impairments of exercise tolerance due to cardiopulmonary impairments. Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.

3. Therapeutic exercise is considered reasonable and necessary if at least 1 of the following conditions is present and documented:

    a. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint ROM, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance

    b. The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, ROM, or endurance as part of ADLs training, or reeducation

4. Documentation for therapeutic exercise typically includes objective loss of joint motion, strength, and/or mobility (e.g., degrees of motion, strength grades, levels of assistance).

Neuromuscular Reeducation

1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Biomechanical Ankle Platform [BAP’s] boards, and desensitization techniques).

2. Neuromuscular reeducation may be considered reasonable and necessary for impairments, which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, tilt table or standing table, hypo/hypertonicity) and improvement of motor control and motor learning.

Aquatic Therapy with Therapeutic Exercises

"Aquatic therapy describes therapeutic exercises performed in a water-based environment. The properties and temperature of the water facilitate movement, particularly for muscles that are compromised due to injury, surgery, or disease (e.g., polio, rheumatoid arthritis, multiple sclerosis, joint arthroplasty)." It is important for the physical therapist to document the need for exercises performed in a water-environment vs land-based exercises. There should be a plan for transitioning from water-based exercises to land-based exercise.

1. This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and necessary for a loss or restriction of joint motion, strength, or mobility (e.g., degrees or motion, strength grades, levels of assistance).

2. Aquatic therapy with therapeutic exercise may be considered reasonable and necessary in the treatment of the following conditions:

a. The patient having pain, joint stiffness or muscle spasms resulting from rheumatoid arthritis

b. The patient having had a cast removed or recent surgery and requiring mobilization of limbs

c. The patient having paraparesis or hemiparesis

d. The patient having had a recent amputation

e. The patient recovering from a paralytic condition

f. The patient requiring limb mobilization after a head trauma

g. The patient having the inability to tolerate exercise for rehabilitation under gravity-based weight bearing

h. The patient having fibromyalgia

Gait Training

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

2. Specific indications for gait training include:

a. The patient having suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation

b. The patient having recently suffered a musculoskeletal trauma requiring gait reeducation

c. The patient having a chronic, progressively debilitating condition, for which safe ambulation has recently become a concern

d. The patient having had an injury or condition that requires instruction in the use of a walker, crutches, or cane

e. The patient having been fitted with a brace/lower limb prosthesis/orthosis and requires instruction in ambulation

f. The patient having a condition that requires retraining in stairs/steps or chair transfer in addition to general ambulation

3. Gait evaluation and training furnished to a patient whose ability to walk has been impaired by neurological, muscular or skeletal abnormality require the skills of a qualified physical therapist and constitute skilled PT and are considered reasonable and necessary, if they can be expected to materially improve or maintain the patient's ability to walk or prevent or slow further deterioration of the patient’s ability to walk. Gait evaluation and training which is furnished to a patient whose ability to walk has been impaired by a condition other than a neurological, muscular, or skeletal abnormality would, nevertheless, be covered where PT is reasonable and necessary to restore or maintain function or to prevent or slow further deterioration.

Massage Therapy

1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment, as well as, a treatment tool.

2. Massage therapy, including effleurage, pétrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

a. The patient having paralyzed musculature contributing to impaired circulation

b. The patient having sensitivity of tissues to pressure

c. The patient having tight muscles resulting in shortening and/or spasticity of affective muscles

d. The patient having abnormal adherence of tissue to surrounding tissue

e. The patient requiring relaxation in preparation for neuromuscular reeducation or therapeutic exercise

f. The patient having contractures and decreased ROM

3. In most cases, postural drainage and pulmonary exercises can be carried out safely and effectively by nursing personnel. To be considered for payment, the physical therapist must identify the intervention that is best suited for the patient, taking into consideration the patient’s condition and any contraindications that may be present. As there can be an overlap of skills between disciplines, i.e., respiratory therapy, skilled nursing and PT, the documentation must clearly support the need for the intervention to be provided by the physical therapist.

Manual Therapy

1. Joint Mobilization (Peripheral or Spinal)

This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

2. Soft Tissue Mobilization

This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue.

Soft tissue mobilization can be considered reasonable and necessary if at least 1 of the following conditions is present and documented:

a. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk

b. Treatment being a necessary adjunct to other PT interventions 

3. Manipulation

This procedure may be considered reasonable and necessary for treatment of painful spasm or restricted motion of soft tissues. It may also be used as an adjunct to other therapeutic procedures.

4. Manual Lymphatic Drainage/Complex Decongestive Therapy

The goal of this type of therapy is to reduce lymphedema by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain the reduction after therapy is complete. This therapy involves intensive treatment to reduce the size by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program.

a. It is expected that during these sessions, education is being provided to the patient and/or caregiver on the correct application of the compression bandage.

b. It is also expected that after the completion of the therapy, the patient and/or caregiver can perform these activities without supervision.

Group Therapeutic Procedures

A group for the purpose of performing group therapy will be defined as:

a. Two or more patients per therapist receiving active therapy but not 1-on-1 treatment, and

b. The patients may be performing the same exercise or a different exercise, but the physical therapist is instructing all the patients in the group.

Orthotic Training

1. This procedure may be considered reasonable and necessary, if there is an indication for education for the application of orthotics, and the functional use of the orthotic is present and documented.

2. Generally, orthotic training can be completed in 3 visits; however, for modification of the orthotic due to healing of tissues, change in edema, or impairment in skin integrity, additional visits may be required.

3. The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training.

4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to apply the device.

Prosthetic Training

1. This procedure may be considered reasonable and necessary, if there is an indication for education in the application of the prosthetic, and the functional use of the prosthetic is present and documented.

2. The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training.

3. Periodic revisits beyond the third month would require documentation to support medical necessity.

Orthotic/Prosthetic Checkout

1. These assessments are reasonable and necessary for "established patients who have already received the orthotic or prosthetic device (permanent or temporary)."

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

3. These assessments may be reasonable and necessary for determining "the patient's response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, under wrap, or socks and determining the patient's tolerance to any dynamic forces being applied."

Therapeutic Activities

1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involve movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a physical therapist and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active written POC and be directed at a specific outcome.

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

a. The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning

b. The patient’s condition being such that he/she is unable to perform therapeutic activities except under the direct supervision of a physician, NPP or physical therapist

c. There being a clear correlation between the type of exercise performed and the patient’s underlying medical condition for which the therapeutic activities were prescribed

Sensory Integrative Techniques 

"Sensory integrative techniques are interventions generally intended for the pediatric and/or neurologically impaired populations. The focus of these activities is to train the sensory systems to modulate the vast array of incoming sensory stimuli. This is something that is normally performed without apparent effort. Once the patient/client learns to block the extrasensory 'noise,' the important sensory input can be processed, and a coordinated motor response can be generated."

Self-Care/Home Management Training

The coverage criteria of self-care management training is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.1.

"Self-care/home management training describes a group of interventions that focuses on ADL skills and compensatory activities needed to achieve independence" or adapt to an evolving deterioration in health and function. "These include activities such as dressing, bathing, food preparation, and cooking. The patient/client may require adaptive equipment and/or assistive technology in the home environment. This may include training the patient/client and/or caregiver in the use of the equipment." 

Community/Work Reintegration

Services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by §1862(a)(1)(A) of the Social Security Act.

"Community/work reintegration training describes interventions intended to facilitate the patient's/client's ability to perform at work and in the community at large. Training could include accessing transportation systems and businesses, analysis of job site modification and work task analysis." 

This training may be medically necessary when performed in conjunction with a patient's individual treatment plan aimed at improving or restoring specific community functions which were impaired by an identified illness or injury and when realistically expected outcomes are specified in the plan. This includes training in the use of assistive technology to assist with mobility, seating systems, and environmental control systems for use in the community. 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.

Work Hardening/Conditioning

"Work hardening and work conditioning are different interventions. Work hardening is an interdisciplinary program that is focused on tasks required for a specific job and uses real or simulated work activities to restore physical, behavioral, and vocational functions. Work hardening addresses productivity, safety, physical tolerances, and worker behavior. In contrast, work conditioning describes a work-related, intensive treatment program designed to restore strength, flexibility, and function so that the patient/client can return to work." These interventions are not covered.

Wheelchair Management Training

Wheelchair management "includes assessing if the patient/client needs a wheelchair, determining what kind of wheelchair is appropriate, including its size and components, measuring the patient/client to ensure proper fit, and fitting the patient/client into the chair once it is received. This includes the time associated with training the patient/client and/or caregiver in transfers in and out of the chair as well as propulsion on all surfaces. It is important for the therapist to provide instructions for safety so as not to risk skin breakdown or a fall."

1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who use wheelchairs for mobility may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.

2. This procedure is reasonable and necessary only when it requires the skills of a physical therapist and is designed to address specific needs of the patient and must be part of an active written POC directed at a specific goal.

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

4. Typically, 3 to 4 sessions should be sufficient to teach the patient and/or caregiver these skills.

5. Documentation should relate training to expected functional goals when providing wheelchair propulsion training.

Physical Performance Test or Measurement

This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific written plan of treatment, or to determine a patient's functional capacity.

Assistive Technology Assessment

This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the patient's status since the last visit and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or re-evaluation is indicated.

Canalith Repositioning Procedure(s) (e.g., Epley maneuver, Semont maneuver)

Canalith repositioning procedure describes a series of movements of the patient's body and head used for the treatment of benign paroxysmal positional vertigo (BPPV). The procedure is used to move displaced calcium crystal debris from the semicircular canals.

Summary of Evidence

N/A

Analysis of Evidence (Rationale for Determination)

N/A

Proposed Process Information

Synopsis of Changes
Changes Fields Changed
N/A
Associated Information
Sources of Information
Bibliography
Open Meetings
Meeting Date Meeting States Meeting Information
N/A
Contractor Advisory Committee (CAC) Meetings
Meeting Date Meeting States Meeting Information
N/A
MAC Meeting Information URLs
N/A
Proposed LCD Posting Date
Comment Period Start Date
Comment Period End Date
Reason for Proposed LCD
Requestor Information
This request was MAC initiated.
Requestor Name Requestor Letter
View Letter
N/A
Contact for Comments on Proposed LCD

Coding Information

Bill Type Codes

Code Description

Please accept the License to see the codes.

N/A

Revenue Codes

Code Description

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CPT/HCPCS Codes

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N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

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

Group 1

Group 1 Paragraph:

N/A

Group 1 Codes:

N/A

N/A

Additional ICD-10 Information

General Information

Associated Information

Documentation Requirements

Coverage criteria for outpatient therapy services and documentation requirements are found in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.3.

1. Documentation supporting medical necessity should be legible and support those services were covered and performed. This documentation must be made available to the A/B MAC upon request.

2. The documentation in the medical records should have sufficient information to determine that a service was performed on specific dates, and the medical necessity of the service(s) rendered.

3. If the signed order includes a POC, no further certification of the plan is required. Payment is dependent on the certification of the POC rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.

4. Required documentation:

  • Evaluation and POC including any other pertinent characteristics of the beneficiary
  • Certifications and recertifications
  • The history and physical exam pertinent to the patient’s care, (including the response or changes in behavior to previously administered skilled services)
  • The skilled services provided
  • A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
  • The complexity of the service to be performed
  • Progress reports written by the clinician - Services related to progress reports are to be furnished on or before every 10th treatment day
  • Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes)
  • The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment and must be written by the clinician
  • When appropriate, a justification statement for services that are more extensive than is typical for the condition treated
  • Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. It is not required that the same physician/NPP who participated initially in recommending or planning the patient's care certify and/or recertify the plans.

NOTE: Documentation must comply with the elements outlined in CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.3 Documentation Requirements for Therapy Services.

5. Documentation should justify:

- the individual is under the care of a physician or NPP
- services require the skills of a therapist
- services are of the appropriate type, frequency, intensity and duration for the individual needs of the patient

6. For restorative/rehabilitative therapy documentation should establish:

- variables that influence the patient's condition
- services provided at the time of treatment
- objective measurements that the patient is making progress toward goals. If it becomes apparent at some point that the goal set for the patient is no longer a reasonable one, then the treatment goal itself should be promptly and appropriately modified to reflect this, and the patient should then be reassessed to determine whether the treatment goal as revised continues to require the provision of skilled services.
- clinical rationale for continued treatment and/or reasons for lack of progress
- recommended changes to the POC
- ongoing reassessment of the patients response to treatment

7. For maintenance therapy:

It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. In situations where the maintenance program is performed to maintain the patient’s current condition, such documentation would serve to demonstrate the program’s effectiveness in achieving this goal. When the maintenance program is intended to slow further deterioration of the patient’s condition, the efficacy of the services could be established by documenting that the natural progression of the patient’s medical or functional decline has been interrupted. Assessments of all goals must be performed in a frequent and regular manner so that the resulting documentation provides a sufficient basis for determining the appropriateness of coverage.

The maintenance program provisions do not apply to the PT services furnished in a comprehensive outpatient rehabilitation facility (CORF) because the statute specifies that CORF services are rehabilitative.

8. CORF social and/or psychological services do not include services for mental health diagnoses. Social and/or psychological services are covered only if the patient's physician or the CORF physician establishes that the services directly relate to the patient's rehabilitation plan of treatment and are needed to achieve the goals in the rehabilitation plan of treatment. Social and/or psychological services are those services that address the patient's response and adjustment to the rehabilitation treatment plan; rate of improvement and progress towards the rehabilitation goals, or other services as they directly relate to the PT plan of treatment being provided to the patient.

Sources of Information

N/A

Bibliography

A Payer’s Guide to Interventions Provided by Physical Therapists and Related CPT Coding. 2nd ed. Alexandria, VA. 2006.

American Medical Association. Coding communication: Orthotic management and prosthetic management. CPT Assistant. February 2007;17(2):8-9,12.

American Medical Association. Coding consultation: Questions and answers. CPT Assistant. July 2004;14(7):13.

American Medical Association. Coding update: Physical medicine and rehabilitation services frequently asked questions. CPT Assistant. February 2004;14(2):5-6.

American Medical Association. Medicine: Physical medicine and rehabilitation, 97110-97139,97150 (q&a). CPT Assistant. August 2006;16(8):11.

American Medical Association. Physical medicine and rehabilitation services, part 1. CPT Assistant. December 2003;13(12):6.

Andrews JR, Harrelson GL, Wilk KE. Physical Rehabilitation of the Injured Athlete. Philadelphia:W. B. Saunders Company;2004.

Ben-Yishay Y, Diller L. Cognitive remediation in traumatic brain injury: Update and issues. Archives of Physical Medicine and Rehabilitation. 1993;74(2):204-213.

Birrer RB. Sports Medicine for the Primary Care Physician. 2nd ed. Boca Raton: CRC Press;1994.

DeLisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. Philadelphia:J.B. Lippincott Company;1993.

Frey WD. Functional Assessment in the 80’s: A Conceptual Enigma; A Technical Challenge. In Halpern AS, Fuhrer MJ, eds. Functional Assessment in Rehabilitation. Baltimore: Paul H. Brookes; 1984.

Griffin JW, Newsome LS, Stralka SW, Wright PE. Reduction of chronic posttraumatic hand edema: A comparison of high voltage pulsed current, intermittent pneumatic compression, and placebo treatments. Physical Therapy. 1990;70(5):279-286.

Guide to Physical Therapist Practice. Alexandria, VA: American Physical Therapy Association (APTA). 1997. Revised April 1999.

Harley JP, Allen C, Braciszewski TL, et al. Guidelines for cognitive rehabilitation. NeuroRehabilitation. 1992;2(3):62-67.

International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization;2001.

Kottke FJ, Lehmann JF, eds. Krusen's Handbook of Physical Medicine and Rehabilitation. 4th ed. Philadelphia:W.B. Saunders Company; 1990.

Matsumura BA, Ambrose AF. Balance in the elderly. Clinics in Geriatric Medicine. 2006;22(2):395-412.

Puett DW, Griffin MR. Published trials of nonmedicinal and noninvasive therapies for hip and knee osteoarthritis. Annals of Internal Medicine. 1994;121(2):133-140.

Studenski SA, Duncan PA, Maino JH. Principles of Rehabilitation in Older Patients. Principles of Geriatric Medicine and Gerontology. In: Hazzard WR, Blass JP, Ettinger WH, Halter JB, Ouslander JG, eds. New York; The McGraw Hill Companies, Inc;1999:435-455.

Revision History Information

Revision History Date Revision History Number Revision History Explanation Reasons for Change
05/18/2023 R22

Under CMS National Coverage Policy updated section headings for regulations. The following regulation was removed and placed in the related Billing and Coding: Outpatient Physical Therapy A53065 article: CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, §30 Rules for Provision of Services and §30.1 Rules for Payment of CORF Services. The following regulation was removed: CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.1 Conditions of Coverage and Payment for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services. Typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
12/08/2022 R21

Under CMS National Coverage Policy deleted “CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Transmittal 179, dated January 14, 2014, Change Request 8458.”

Under Associated Information revised section #4 to state:

“4. Required documentation:

  • Evaluation and POC including any other pertinent characteristics of the beneficiary
  • Certifications and recertifications
  • The history and physical exam pertinent to the patient’s care, (including the response or changes in behavior to previously administered skilled services)
  • The skilled services provided
  • A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
  • The complexity of the service to be performed
  • Progress reports written by the clinician - Services related to progress reports are to be furnished on or before every 10th treatment day
  • Treatment notes for each treatment day (may also serve as progress reports when required information is included in the notes)
  • The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment and must be written by the clinician
  • When appropriate, a separate justification statement for services that are more extensive than is typical for the condition treated
  • Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or recertified to complete the certification requirements. It is not required that the same physician/NPP who participated initially in recommending or planning the patient's care certify and/or recertify the plans.

NOTE: Documentation must comply with the elements outlined in CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.3 Documentation Requirements for Therapy Services.”

Under Bibliography changes were made to citations to reflect AMA citation guidelines. Acronyms were inserted and defined where appropriate throughout the LCD. Formatting, punctuation and typographical errors were corrected throughout the LCD.

  • Provider Education/Guidance
  • Other (LCD revision that makes a Non-Discretionary Coverage Update - Contractors shall update LCDs to reflect changes in Statutes, Federal regulations, CMS Rulings, NCDs, HCPCS code changes for DME, coverage provisions in interpretive manuals, and payment policies.)
03/25/2021 R20

Under CMS National Coverage Policy corrected regulation 42 CFR from §410.3(b)(3) to §410.32(b)(3), moved regulation CMS Internet-Only Manual, Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, §220.4 to the related billing and coding article, and added section headings to the regulations. Under Coverage Indications, Limitations and/or Medical Necessity corrected regulation 42 CFR from §410.3(b)(3) to §410.32(b)(3) in fourth paragraph. Under Bibliography changes were made to citations to reflect AMA citation guidelines. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were defined and inserted where appropriate throughout the LCD.

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
11/14/2019 R19

This LCD is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs. There has been no change in coverage with this LCD revision. Regulations regarding billing and coding were removed from the CMS National Coverage Policy section of this LCD and under Coverage Indications, Limitations and/or Medical Necessity Rehabilitation services for vision impairment: the coverage criteria and definition of rehabilitation services for beneficiaries with vision impairment are found in Program Memorandum, Transmittal AB-02-078, dated May 29, 2002, Change Request 2083.” was removed and placed in the placed in the related Billing and Coding: Outpatient Physical Therapy A53065 article.

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
08/22/2019 R18

All coding located in the Coding Information section has been moved into the related Billing and Coding: Outpatient Physical Therapy A53065 article and removed from the LCD. 

All verbiage regarding billing and coding under the Coverage Indications, Limitations and/or Medical Necessity section has been removed and is included in the related Billing and Coding: Outpatient Physical Therapy A53065 article.

Under CMS National Coverage Policy added 42 CFR §410.3 (b) (3).  

Under Coverage Indications, Limitations and/or Medical Necessity removed quoted Internet Only Manual (IOM) text in the fourth paragraph and changed verbiage to read “For the purposes of this Local Coverage Determination (LCD), the descriptions/definitions of supervision are those given in 42 CFR §410.3(b)(3).” Removed quoted Internet Only Manual (IOM) text in the tenth and eleventh paragraphs and changed verbiage to read “Some services must be provided by a licensed therapist and may not be performed by a physical therapy assistant such services include: Making clinical judgements or decisions; Developing, managing or furnishing skilled maintenance programs; Supervising other clinicians or taking responsibility for the service rendered: Acting outside of the directions and supervision of a treating physical therapist in accordance with state laws.” Under subheading Maintenance Therapy Necessity removed quoted Internet Only Manual (IOM) text in the fourth paragraph and changed verbiage to read “A maintenance program is a program designed to maintain or to slow deterioration as described in the CMS Internet-Only Manual Pub.100-02, Medicare Benefit Policy Manual, Chapter 15, §220. A maintenance program must meet these criteria to be considered reasonable and necessary.”  Under GENERAL PHYSICAL THERAPY GUIDELINES removed quoted Internet Only Manual (IOM) text from #5. Under subheading Maintenance Programs verbiage was changed to read ”A maintenance program is a program intended to maintain function or slow the decline in function. Coverage of skilled rehabilitation services is contingent upon a beneficiary’s need for skilled care. When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively. Provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient’s unique circumstance.  The provision of therapy services by skilled personnel does not in itself make the service one that requires skilled care.” Under Associated Information subheading Documentation Requirements under #1 changed verbiage to read “Documentation supporting medical necessity should be legible and support that the services billed were covered and performed.” Removed verbiage addressing Functional Reporting in the second paragraph. Under Bibliography changes were made to citations to reflect AMA citation guidelines and retired sources were removed. Formatting, punctuation and typographical errors were corrected throughout the LCD. Acronyms were inserted where appropriate throughout the LCD.

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
01/01/2019 R17

Under Coverage Indications, Limitations and/or Medical Necessity Electrical Stimulation Therapy deleted CPT code 64550 in the subtitle. The second sentence “A separate CPT code 64550 is available for ‘initial application of a TENS unit in which electrodes are placed on the skin’ for patients that will be operating the TENS unit at home” was deleted and replaced with the verbiage, “Report this code only when one-on-one instruction is required for subsequent home use of a TENS unit”. Under CPT/HCPCS Codes Group 1: Codes deleted 64550. This revision is due to the Annual CPT/HCPCS Code Update.

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
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2018 R16

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes ICD-10 code descriptions were revised for the following: L98.495, L98.496, L98.498, S62.626D, S62.626G, S62.626K, S62.626P, S62.626S, S62.627D, S62.627G, S62.627K, S62.627P, S62.627S, S62.654D, S62.654G, S62.654K, S62.654P, S62.654S, S62.655D, S62.655G, S62.655K, S62.655P, S62.655S, S62.656D, S62.656G, S62.656K, S62.656P, S62.656S, S62.657D, S62.657G, S62.657K, S62.657P, and S62.657S. Under ICD-10 Codes That Support Medical Necessity Group 1: Codes deleted ICD-10 codes G71.0, M79.1, T81.4XXD, T81.4XXS and added ICD-10 codes G71.00, G71.01, G71.02, and G71.09. This revision is due to the Annual ICD-10 Code Update and becomes effective October 1, 2018.

Under ICD-10 Codes That Support Medical Necessity Group 1: Codes added ICD-10 code G20 due to a reconsideration request. This revision becomes effective October 1, 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.

  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
  • Reconsideration Request
01/29/2018 R15

Under CMS National Coverage Policy in the first paragraph deleted the second and third sentence. Under Coverage Indications, Limitations, and/or Medical Necessity-PT Evaluation revised the heading verbiage. Punctuation was corrected throughout the LCD. Under Electrical Stimulation Therapy (CPT codes 64550 and 97032, HCPCS code G0283) deleted the second paragraph and replaced the verbiage with the following text, “TENS is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under §1862(a)(1)(A) of the Act.” Under Associated Information-Documentation Requirements 4. italicized manual text in the second set of bullets. Under Bibliography added the year for the following source of information: A Payer’s Guide to Interventions Provided by Physical Therapists and Related CPT Coding. 2nd ed. Alexandria, VA. 2006.

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
  • Other
01/29/2018 R14 The Jurisdiction "J" Part A Contracts for Alabama (10111), Georgia (10211) and Tennessee (10311) are now being serviced by Palmetto GBA. The notice period for this LCD begins on 12/14/17 and ends on 01/28/18. Effective 01/29/18, these three contract numbers are being added to this LCD. No coverage, coding or other substantive changes (beyond the addition of the 3 Part A contract numbers) have been completed in this revision.
  • Change in Affiliated Contract Numbers
01/01/2018 R13

Under Coverage Indications, Limitations and/or Medical Necessity deleted 97762 and added 97763 under Orthotic/Prosthetic Checkout (CPT code 97763). Under CMS National Coverage Policy added CMS Manual System, Pub 100-04, Medicare Claims Processing Manual, Transmittal 3924, dated November 16, 2017, Change Request 10303. Under CPT/HCPCS Codes Group 1: Codes deleted 97762 and added 97763 and the description was revised for 64550, 97760 and 97761. This revision is due to the Annual CPT/HCPCS Code Update.

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
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2017 R12

Under ICD-10 Codes That Support Medical Necessity Group 1:Codes added ICD-10 codes G12.23, G12.24, G12.25, L97.115, L97.116, L97.118, L97.125, L97.126, L97.128, L97.215, L97.216, L97.218, L97.225, L97.226, L97.228, L97.315, L97.316, L97.318, L97.325, L97.326, L97.328, L97.415, L97.416, L97.418, L97.425, L97.426, L97.428, L97.515, L97.516, L97.518, L97.525, L97.526, L97.528, L97.815, L97.816, L97.818, L97.825, L97.826, L97.828, L97.915, L97.916, L97.918, L97.925, L97.926, L97.928, L98.415, L98.416, L98.418, L98.425, L98.426, L98.428, L98.495, L98.496, L98.498, M48.061, and M48.062. Under ICD-10 Codes That Support Medical Necessity Group 1:Codes deleted ICD-10 codes H54.0, H54.2, M48.06, S63.131A, S63.131D, S63.131S, S63.132A, S63.132D, S63.132S, S63.134A, S63.134D, S63.134S, S63.135A, S63.135D, S63.135S, S63.141A, S63.141D, S63.141S, S63.142A, S63.142D, S63.142S, S63.144A, S63.144D, S63.144S, S63.145A, S63.145D, and S63.145S. Under ICD-10 Codes That Support Medical Necessity Group 1:Codes the code description was revised for ICD-10 codes I83.811, I83.812, I83.891, I83.892, S62.311D, S62.311G, S62.311K, S62.311P, S62.311S, S62.317D, S62.317G, S62.317K, S62.317P, S62.317S, S62.341D, S62.341G, S62.341K, S62.341P, S62.341S, S62.347D, S62.347G, S62.347K, S62.347P, S62.347S, S62.620D, S62.620G, S62.620K, S62.620P, S62.620S, S62.621D, S62.621G, S62.621K, S62.621P, S62.621S, S62.622D, S62.622G, S62.622K, S62.622P, S62.622S, S62.623D, S62.623G, S62.623K, S62.623P, S62.623S, S62.624D, S62.624G, S62.624K, S62.624P, S62.624S, S62.625D, S62.625G, S62.625K, S62.625P, S62.625S, S62.650D, S62.650G, S62.650K, S62.650P, S62.650S, S62.651D, S62.651G, S62.651K, S62.651P, S62.651S, S62.652D, S62.652G, S62.652K, S62.652P, S62.652S, S62.653D, S62.653G, S62.653K, S62.653P, S62.653S, S63.121A, S63.121D, S63.121S, S63.122A, S63.122D, S63.122S, S63.124A, S63.124D, S63.124S, S63.125A, S63.125D, S63.125S, S92.521A, S92.521B, S92.521D, S92.521G, S92.521K, S92.521P, S92.521S, S92.522A, S92.522B, S92.522D, S92.522G, S92.522K, S92.522P, S92.522S, S92.524A, S92.524B, S92.524D, S92.524G, S92.524K, S92.524P, S92.524S, S92.525A, S92.525B, S92.525D, S92.525G, S92.525K, S92.525P, and S92.525S. This revision is due to the 2017 Annual ICD-10 Code Updates. Under ICD-10 Codes That Support Medical Necessity- Group 1: Codes added L59.8 due to a reconsideration request.

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
  • Revisions Due To ICD-10-CM Code Changes
  • Reconsideration Request
03/16/2017 R11 Revisions were made to the Outpatient Physical Therapy local coverage determination (LCD) L34428. Under Sources of Information and Basis for Decision- Revision to author name for book Physical Rehabilitation of the injured athlete to read Wilk, KE. Revised title of book to add apostrophe “Krusen’s Handbook of Physical Medicine and Rehabilitation”. Delete reference “Physical Medicine and Rehabilitation Practice Guidelines. 1st ed. Seccion De. Fisiatria, Asociacion Medica De Puerto Rico; 1995”. Correction to author for Principles of Geriatric Medicine and Gerontology, to read “Duncan PA”. Correction to title of journal removed “Am Acad” and replaced with correct title “Neurology”. Updated reference to reflect most current version; Wound, Ostomy and Continence Nurses Society. Conservative Sharp Wound Debridement for Nurses. Journal WOC Nurses. 1995; 22(1): 32A, 34A. Revision to reference to correct the page number from 14 to 13 in American Medical Association. CPT Assistant. July 2004; 14(7): 13.
  • Provider Education/Guidance
  • Typographical Error
01/01/2017 R10 Under CMS National Coverage Policy added Change Request 9782, Transmittal 3654. Under Coverage Indications, Limitations, and/or Medical Necessity-Specific Procedure and Modality Guidelines the short description verbiage was revised for CPT 97602 to now read wound(s) care non-selective debridement and corrected the verbiage for CPT codes 97605 and 97606 to now read negative pressure wound therapy. Under PT Evaluation deleted CPT code 97001 and added the new CPT codes 97161, 97162, and 97163 for low complex, moderate complex and high complex respectively and deleted CPT code 97002 and added CPT code 97164 for PT Re-evaluation. Under Electrical Stimulation (ES) Therapy HCPCS G0281 added “unattended” as the description changed. Under CPT/HCPCS Codes deleted CPT codes 97001 and 97002 and added CPT codes 97161, 97162, 97163 and 97164. This revision is due to the 2017 Annual CPT/HCPCS Code Update
  • Provider Education/Guidance
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2016 R9 Under ICD-10 Codes That Support Medical Necessity: Group 1 added G56.03, G56.13, G56.23, G56.33, G56.43, G56.83, G56.93, G57.03, G57.13, G57.23, G57.33, G57.43, G57.53, G57.63, G57.73, G57.83, G57.93, G61.82, I69.010, I69.011, I69.012, I69.013, I69.014, I69.015, I69.018, I69.019, I69.110, I69.111, I69.112, I69.113, I69.114, I69.115, I69.118, I69.119, I69.210, I69.211, I69.212, I69.213, I69.214, I69.215, I69.218, I69.219, I69.310, I69.311, I69.312, I69.313, I69.314, I69.315, I69.318, I69.319, I69.810, I69.811, I69.812, I69.813, I69.814, I69.815, I69.818, I69.910, I69.911, I69.912, I69.913, I69.914, I69.915, I69.918, M25.541, M25.542, M50.020, M50.021, M50.022, M50.023, M50.121, M50.122, M50.123, M84.750S, M84.751S, M84.752S, M84.754S, M84.755S, M84.757S, M84.758S, M97.01XD, M97.01XS, M97.02XD, M97.02XS, M97.11XD, M97.11XS, M97.12XD, M97.12XS, M97.21XD, M97.21XS, M97.22XD, M97.22XS, M97.31XD, M97.31XS, M97.32XD, M97.32XS, M97.41XD, M97.41XS, M97.42XD, M97.42XS, S03.01XD, S03.01XS, S03.02XD, S03.02XS, S03.03XD, S03.03XS, S92.811D, S92.811S, S92.812D, S92.812S, S99.001D, S99.001S, S99.002D, S99.002S, S99.011D, S99.011S, S99.012D, S99.012S, S99.021D, S99.021S, S99.022D, S99.022S, S99.031D, S99.031S, S99.032D, S99.032S, S99.041D, S99.041S, S99.042D, S99.042S, S99.091D, S99.091S, S99.092D, S99.092S, S99.101D, S99.101S, S99.102D, S99.102S, S99.111D, S99.111S, S99.112D, S99.112S, S99.121D, S99.121S, S99.122D, S99.122S, S99.131D, S99.131S, S99.132D, S99.132S, S99.141D, S99.141S, S99.142D, S99.142S, S99.191D, S99.191S, S99.192D, S99.192S, S99.201D, S99.201S, S99.202D, S99.202S, S99.211D, S99.211S, S99.212D, S99.212S, S99.221D, S99.221S, S99.222D, S99.222S, S99.231D, S99.231S, S99.232D, S99.232S, S99.241D, S99.241S, S99.242D, S99.242S, S99.291D, S99.291S, S99.292D, S99.292S, T82.855D, T82.855S, T82.856D and T82.856S. Under ICD-10 Codes That Support Medical Necessity: Group 1 deleted M26.60, M26.61, M26.62, M26.63, M50.02, M50.12, M50.22, M50.32, M50.82, M50.92, N50.8, S02.10XD, S02.10XG, S02.10XK, S02.10XS, S02.3XXD, S02.3XXG, S02.3XXK, S02.3XXS, S02.61XD, S02.61XG, S02.61XK, S02.61XS, S02.62XD, S02.62XG, S02.62XK, S02.62XS, S02.63XD, S02.63XG, S02.63XK, S02.63XS, S02.64XD, S02.64XG, S02.64XK, S02.64XS, S02.65XD, S02.65XG, S02.65XK, S02.65XS, S02.67XD, S02.67XG, S02.67XK, S02.67XS, S02.8XXD, S02.8XXG, S02.8XXK, S02.8XXS, S03.0XXA, S03.0XXD, S03.0XXS, S03.4XXA, S03.4XXD, S03.4XXS, S06.0X2D, S06.0X2S, S06.0X3D, S06.0X3S, S06.0X4D, S06.0X4S, S06.0X5D, S06.0X5S, T84.040D, T84.040S, T84.041D, T84.041S, T84.042D, T84.042S, T84.043D, T84.043S, T84.048D, T84.048S, T85.82XD, T85.82XS, T85.84XD, T85.84XS, T85.85XD, T85.85XS, T85.86XD, T85.86XS, T85.89XD and T85.89XS. Under ICD-10 Codes That Support Medical Necessity: Group 1 revised code descriptions for S02.110D, S02.110G, S02.110K, S02.110S, S02.111D, S02.111G, S02.111K, S02.111S, S02.112D, S02.112G, S02.112K, S02.112S, S02.118D, S02.118G, S02.118K, S02.118S, S02.400D, S02.400G, S02.400K, S02.400S, S02.401D, S02.401G, S02.401K, S02.401S, S02.402D, S02.402G, S02.402K, S02.402S, S02.600D, S02.600G, S02.600K, S02.600S, S49.031A, S49.031D, S49.031G, S49.031K, S49.031P, S49.031S, S49.032A, S49.032D,S49.032G, S49.032K, S49.032P, S49.032S, S49.039A, S49.039D, S49.039G, S49.039K, S49.039P, S49.039S, S49.131A, S49.131D, S49.131G, S49.131K, S49.131P, S49.131S, S49.132A, S49.132D, S49.132G, S49.132K, S49.132P, S49.132S, S49.139A, S49.139D, S49.139G, S49.139K, S49.139P, S49.139S, S54.8X1A, S54.8X1D, S54.8X1S, S54.8X2A, S54.8X2D, S54.8X2S, T82.848D, T82.848S, T82.858D, T82.858S, T82.868D, T82.868S, T85.111D, T85.111S, T85.112D, T85.112S, T85.121D, T85.121S, T85.122D, T85.122S, T85.191D, T85.191S, T85.192D and T85.192S. This revision is due to the Annual ICD-10 Code Update and becomes effective 10/01/16.
  • Revisions Due To ICD-10-CM Code Changes
08/04/2016 R8 Under ICD-10 Codes that Support Medical Necessity added G80.0, G80.1, G80.2, G80.4, G80.8 and G80.9.
  • Reconsideration Request
03/10/2016 R7 Throughout the LCD language quoted from the Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals was italicized. Punctuation was corrected throughout the LCD. Under Coverage Indications, Limitations and/or Medical Necessity corrected the title for the section on Biofeedback training (CPT codes 90901 and 90911). The title was corrected for CPT codes 97022 and 97036 to now read Whirlpool Therapy/Hubbard Tank. Under Electrical Stimulation (ES) Therapy (HCPCS G0281) revised CMS Manual System to now read CMS Internet-Only Manual. Under Contrast Baths (CPT code 97034) #4 revised “whirlpool” to now read “contrast”. Under Therapeutic Activities (CPT code 97530) 1. deleted the “s” from involves in the first sentence and added “a” in the sentence and deleted the “s” from therapists in the last sentence. Under Bill Type Codes added multiple bill types. Under Sources of Information and Basis for Decision added author initials for DeLisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. Philadelphia:J.B. Lippincott Company;1993 and corrected the published date and deleted “Physical Therapy” for Puett DW, Griffin MR. Published Trials of Nonmedicinal and Noninvasive Therapies for Hip and Knee Osteoarthritis. Annals of Internal Medicine.
  • Provider Education/Guidance
  • Other
02/04/2016 R6 Under ICD-10 Codes That Support Medical Necessity added the 7th character to numerous ICD-10 codes found in the S00-T88 family of codes.
  • Reconsideration Request
10/01/2015 R5 Under Bill Type Codes the description changed for bill type 034 due to the National Uniform Billing Code (NUBC) 2015 First and Second Quarter Updates.
  • Provider Education/Guidance
  • Other (Bill Type Code Changes)
10/01/2015 R4 Under Coverage Indications, Limitations and /or Medical Necessity under the Electrical Stimulation Therapy section removed code G0281 and created a section Electrical Stimulation (ES) Therapy HCPCS G0281 Electrical Stimulation Therapy and definition are found in the CMS Manual System, Pub 100-03, Medicare National Coverage determinations Manual, Chapter 1, Part 4, §270.1.
  • Provider Education/Guidance
  • Other (Change request 8109.)
10/01/2015 R3 Under CMS National Coverage Policy corrected the citation for 42 CFR, §§424.24 and 410.61, added verbiage to the citation for 42 CFR, §§424.24 and 410.61 and deleted §20 from the following: CMS Internet-Only Manual, Pub. 100-02, Medicare Benefit Policy Manual, Chapter 12, §§10, 20.1, 20.2, 30, 30.1, 40.1, 40.2, and 40.7. The following manual citation was added: CMS Internet-Only Manual, Pub 100-04, Medicare Claims Processing Manual, Chapter 5, §10.6 and 42 CFR, §409.32. Under CMS National Coverage Policy-Program Memorandum changed CMS Internet-Only Manual to read CMS Manual System.The following Change Request was added: CMS Manual System, Pub 100-02, Medicare Benefit Policy Manual, Transmittal 179, dated January 14, 2014, Change Request 8458. The following Change Requests were deleted as the information has now been added to the Internet-Only Manuals- Change Requests 8005, Transmittals 165 and 2622, dated December 21, 2012. Under Coverage Indications, Limitations and/or Medical Necessity-General Physical Therapy Guidelines #3 added “treatment” to the third sentence. Under Coverage Indications, Limitations and/or Medical Necessity-Casts and Strapping throughout the section corrected “tendinitis” to now read “tendonitis”. Under Coverage Indications, Limitations and/or Medical Necessity-Lower Extremity Casts deleted the verbiage regarding Application of Foot Splint (CPT code 29590). Under Coverage Indications, Limitations and/or Medical Necessity deleted Electromagnetic Therapy (HCPCS G0329) as this was redundant. Under Coverage Indications, Limitations and/or Medical Necessity-Maintenance Programs deleted the last paragraph as this was quoted from the Medicare Benefit Policy Manual-Home Health Services. Under Coverage Indications, Limitations and/or Medical Necessity-General Guidelines for Therapeutic Procedures #5 deleted the “s” from “Requires”. Under Coverage Indications, Limitations and/or Medical Necessity- Self Care/Home Management deleted “…and definition” from the first sentence. Punctuation was corrected throughout the entire LCD. Under CPT/HCPCS Codes added CPT code 97533 as this was inadvertently omitted from the list. Under Associated Information-Documentation Requirements #1 deleted “the” in the sentence. Under Associated Information-Documentation Requirements #4-Required documentation related to progress notes, revised “service” to now read “services”. Under Associated Information-Documentation Requirements added “hospitals” to the paragraph on functional reporting and italicized the paragraph listing those responsible for documenting functional reporting. Under Sources of Information and Basis for Decision references were added including the following: multiple cited CPT Assistants and Coding Consultation; International Classification of Functioning, Disability and Health (ICF). Geneva: World Health Organization;2001 and Matsumura BA, Ambrose AF. Balance in the Elderly. Clinics in Geriatric Medicine. 2006;22(2):395-412. Author names and initials were added and corrected, supplement and volume numbers were added, typographical errors were corrected, and specific years of publication were added to several references. The following reference was deleted as it was redundant: A Guide to Physical Therapist Practice. American Physical Therapy Association. 1997.
  • Provider Education/Guidance
  • Typographical Error
10/01/2015 R2 Under CPT/HCPCS Codes revisions were made to the description for 97605 and 97606.
  • Revisions Due To CPT/HCPCS Code Changes
10/01/2015 R1 Under ICD-10 Codes That Support Medical Necessity effective 06/29/2014, the following invalid codes were deleted due to the 2014 & 2015 Annual ICD-10 Code Update: M47.17, M47.18, and M51.07. Under ICD-10 Codes That Support Medical Necessity effective 06/29/2014, ICD-10 code description verbiage was revised due to the 2014 & 2015 Annual ICD-10 Code Update for the following: M08.88, M12.08, M12.28, M12.38, M12.58, M12.88, M25.08, M25.18, M50.01, M50.11, M50.21, M50.31, M50.81, M50.91, and M84.58XS. Under Sources of Information and Basis for Decision deleted the cited HBO LCD listed under relevant LCDs as this LCD was retired. This revision becomes effective 10/01/2014.
  • Provider Education/Guidance
  • Revisions Due To ICD-10-CM Code Changes
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Keywords

  • Physical Therapy
  • PT

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