Document Information
LCD ID
L33631
LCD Title
Outpatient Physical and Occupational Therapy Services
Proposed LCD in Comment Period
N/A
Source Proposed LCD
DL33631
Original Effective Date
For services performed on or after 10/01/2015
Revision Effective Date
For services performed on or after 01/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
Notice Period Start Date
N/A
Notice Period End Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement CPT codes, descriptions and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is notrecommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services.The AMA assumes no liability for data contained or not contained herein. Current Dental Terminology © 2022 American Dental Association. All rights reserved. Copyright © 2022, the American Hospital Association, Chicago, Illinois. Reproduced with permission.No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.
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: 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. 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, Vol. 72, No. 227, November 27, 2007, pages 66328-66333 and 66397-66408, and the correction notice for this rule, published in the Federal Register on January 15, 2008, pages 2431-2433, addresses 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: CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15: 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 V57.1-V57.89 ICD-9-CM codes. CMS Transmittal No. 4149, Publication 100-04, Medicare Claims Processing Manual, October 23, 2018, removes Functional Reporting requirements and edits for outpatient therapy services. CMS Transmittal No. 179, Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius, Change request #8458, January 14, 2014, provides clarification that coverage of skilled nursing and skilled therapy services “…does not turn on the presence or absence of a beneficiary’s potential for improvement, but rather on the beneficiary’s need for skilled care.”220 through 230 Coverage and documentation requirements for physical and occupational therapy services.
CMS Publication 100-03, Medicare National Coverage Decisions (NCD) 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.
Coverage Guidance
Coverage Indications, Limitations, and/or Medical Necessity Medical Necessity 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. Refer to CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, section 220.2(C). 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. 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. 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. Services related to recreational activities such as golf, tennis, running, etc., arenot covered as therapy services. The services that are provided must meet the description of skilled therapy below. Skilled Therapy Consider the followingwhen determining if a service is skilled. 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 to prevent or slow further deterioration in functional status. Personnel Authorized to Provide Outpatient Therapy Services *Please refer to the LCD for Speech Language Pathology (L33580) for further coverage information on speech language pathology services. Personnel NOT Authorized to Provide Outpatient Therapy Services *See Therapy Students section in the related Billing and Coding article 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. Private Practice Therapy Services 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. Indications and Limitations of Coverage and/or Medical Necessity for specific modalities and procedures: 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. 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. Documentation must be sufficient to demonstrate the specifics of the therapy provided so that it may be determined that the treatment was medically necessary. 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. Physical therapy evaluation 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, reflecting the level of complexity of the evaluation, 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. 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. 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. Consider the following points when billing for an evaluation. Physical therapy reevaluation 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. MODALITIES 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. Hot or cold packs (to one or more areas) Traction, Mechanical (to one or more 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. Equipment and tables utilizing roller systems are not considered true mechanical traction. Services using this type of equipment are non-covered. Vasopneumatic Devices (to one or more areas) 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. Paraffin Bath (to one or more areas) Whirlpool (to one or more areas) Dry hydrotherapy massage (also known as aquamassage, hydromassage, or water massage) is considered investigational and is non-covered. Diathermy (i.e., microwave) 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) 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. Ultraviolet (to one or more areas) Electrical stimulation (manual) (to one or more areas), each 15 minutes 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). 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. Iontophoresis (to one or more areas) 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 hyperhidrosisthat 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 (to one or more areas) 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. 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. Ultrasound (to one or more areas) 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: Ultrasound application is not considered reasonable and necessary for the treatment of: 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. It is not medically necessary to have more than one form of hydrotherapy during a visit. 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). Non-Implantable Pelvic Floor Electrical Stimulation THERAPEUTIC PROCEDURES General Guidelines for Therapeutic Procedures Therapeutic procedures attempt to reduce impairments and restore function through the application of clinical skills and/or services. Use of these procedures is expected to result in improvement of the limitations/deficits in a reasonable and generally predictable period of time. 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. Therapeutic Exercises to develop strength and endurance, range of motion and flexibility (one or more areas, each 15 minutes) 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, or weight reduction, are not covered. Maintenance exercises to maintain range of motion and/or strength may only be covered when all criteria above for skilled maintenance therapy are met. 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. 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. Neuromuscular Re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (one or more areas, each 15 minutes) This procedure may be reasonable and necessary for restoring prior function which has been affected by: Vestibular ocular reflex training is another example where the service is mainly a patient self-directed therapy exercise following initial education. There is moderate evidence that correctly educated patients benefit from performing these exercises regularly in their home. This training can be an integral component, but not a separately payable service, of appropriate balance and gait re-training, where clinically indicated. 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: 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. Aquatic Therapy with Therapeutic Exercises (one or more areas, each 15 minutes) 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 and to increased function. The qualified professional/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 weight reduction, are not covered. Exercises in the water environment for maintenance purposes may only be covered when all criteria above for skilled maintenance therapy are met. 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. Consider the following points when providing aquatic therapy services. Gait Training (includes stair climbing) (one or more areas, each 15 minutes) 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: Gait training is not considered reasonable and necessary when the patient’s walking ability is not expected to improve. 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. Coverage for NMES/FES for walking will be covered in SCI patients with all of the following characteristics: (Italicized information about NMES for walking in SCI patients is from CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 160.12) Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) (one or more areas, each 15 minutes) 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. Manual Therapy Techniques (e.g.,mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes Both primary and secondary lymphedemas are chronic and progressive conditions which can be brought under long-term control with effective management. By maintaining control of the lymphedema, patients can: Therapeutic Procedure(s), Group (2 or more individuals) Group therapy procedures involve constant attendance of the physician, NPP, therapist, or assistant, but by definition do not require one-on-one patient contact. 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 Therapeutic Activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes 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 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 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: Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training) direct (one-on-one) patient contact, each 15 minutes 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. Conditions without potential for improvement or restoration, such as chronic progressive brain conditions, would not be appropriate. Evidence-based reviews indicate that cognitive rehabilitation (and specifically memory rehabilitation) is not recommended for patients with severe cognitive dysfunction. Cognitive skill training should be aimed towards improving or restoring 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. Those services that a patient may engage in without a skilled therapist qualified professional/auxiliary personnel are not covered under the Medicare benefit. 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. They are not appropriate for patients with progressive neurological conditions without potential for functional adaptation. 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. Self–care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes 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) in which there is potential for improvement in a functional task 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 that are attainable by the patient. 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 (instrumental activities of daily living) 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. Community/Work Reintegration Training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis) direct one-on-one contact, each 15 minutes 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. 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. Under the Occupational Therapy benefit, this service may be covered for the provision of compensatory training of patients in driving techniques. The patients must be identified as meeting Medicare criteria for coverage: Wheelchair Management (e.g., assessment, fitting, training), each 15 minutes Consider the following points when providing wheelchair management services. Work hardening/conditioning Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (e.g., wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session 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. Note: While debridement is considered a covered service for appropriately selected wounds, the following services are considered non-covered for the treatment of wounds. Negative pressure wound therapy (eg,vacuum assisted drainage collection), utilizing durable medical equipment (dme), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; Negative pressure wound therapy, (eg, vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; Negative pressure wound therapy (NPWT) involves negative pressure to the wound bed to manage wound exudates and promote wound healing. NPWT consists of a sterile sponge held in place with transparent film, a drainage tube inserted into the sponge, and a connection to a vacuum source. 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: Physical Performance Test or Measurement (e.g., musculoskeletal, functional capacity) with written report, each 15 minutes 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. Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes 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). Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes 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. 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. 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. 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. For uncomplicated conditions, the following services would not be considered reasonable and necessary as they would not require the unique skills of a therapist. 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, except when all criteria above for maintenance programs are met. Ongoing therapy visits for increasing wearing time are generally not reasonable and necessary when patient problems related to the orthotic have not been observed. Prosthetic training, upper and/or lower extremity(s), initial prosthetic(s) encounter, each 15 minutes 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. 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. 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 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 Other Available TherapyServices Muscle and Range of Motion Testing 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. 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). Application of Casts, Strapping and Splinting Codes General Guidelines for Casting General Guidelines for Strapping General Guidelines for Splinting 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. Biofeedback training by any modality Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry 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: Biofeedback is non-covered for: Patients not showing improvement after 5-6 visits of retraining with biofeedback are not likely to improve with additional sessions. Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day 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. Miscellaneous Services (Non-covered)
To be considered reasonable and necessary, the services must meet Medicare guidelines. The guidelines for coverage of outpatient therapies have basic requirements in common.
Services that do not require the professional skills of a therapist to perform or supervise are not medically necessary, even if they are performed or supervised by a therapist, physician or NPP. 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.
Medicare billable therapy services may be provided by any of the following within their scope of practice and consistent with state and local law:
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.
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.
Occupational therapy evaluation
Occupational therapy reevaluation
Reevaluation provides additional objective information not included in other documentation, such as treatment or progress notes.
Consider the following points when billing for a reevaluation.
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.
Traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas.
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.
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.
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:
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.
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.
Documentation must clearly support the medical necessity of electrical stimulation more than 12 visits as adjunctive therapy or for muscle retraining.
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.
Hubbard Tank (to one or more areas)
Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
(CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8.)
Therapeutic exercises are used for the purpose of restoring 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).
This therapeutic procedure is provided for the purpose of restoring balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation (PNF), BAP’s boards, vestibular rehabilitation, desensitization techniques, balance and posture training).
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.
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.
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.
Thisservice 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.
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.
NPWT is not covered for:
Physical performance testing may be reasonable and necessary for patients with neurological, musculoskeletal, or pulmonary conditions.
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).
Prosthetic training is the professional instruction necessary for a patient to properly use an artificial device that has been developed to replace a missing body part.
On rare occasions, it may be appropriate to perform a
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.
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.
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.
Canalith repositioning is used for the treatment of benign paroxysmal positional vertigo (BPPV). It is covered when performed by physicians, qualified non-physician providers and therapists. The procedure is covered as a single service per day, regardless of the duration required to provide the service or the number of repeat services. It is anticipated that the frequency and the total number of this service provided would be limited to five or fewer encounters, as the patient may be able to be trained to perform these maneuvers on his/her own without the assistance/supervision of a trained professional. The medical record should include documentation of the plan of care, the patient’s progress, and conditions requiring continued supervision by a trained professional. When provided during the same encounter as an E&M service, subsequent to the diagnosis of and first encounter for the BPPV, a significant and separately identifiable reason supporting the E&M service should be present.
The following are non-covered as skilled therapy services. This is not an all inclusive list.
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