Medical Policies - Therapy
Physical Therapy (PT) and Occupational Therapy (OT) Services
*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*
Physical therapy (PT) and/or occupational therapy (OT) services may be considered medically necessary when PT or OT services fulfill ALL of the following criteria:
• Is reasonably expected to improve function to an individual who suffers from functional impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention; AND
• Will provide durable, condition-specific corrective benefit that is not for maintenance or supportive therapy; AND
• Will achieve durable, condition-specific corrective benefit in a reasonable and predictable period of time (usually four to six months); AND
• Requires the judgment, knowledge, and skills of a qualified provider of PT or OT services due to the complexity and sophistication of the therapy and the physical condition of the patient, and cannot be reasonably taught to and implemented by the affected individual and/or nonprofessional caregivers; AND
• Are delivered to the patient individually by a qualified provider (see NOTE 1) of PT or OT services. [NOTE 1: A qualified provider is one who is licensed where required and performs within the scope of licensure. This may include, but is not limited to, Physical Therapists, Occupational Therapists, Chiropractors, Osteopaths, etc.]; AND
• The following documentation from the medical record is provided:
o That the patient is under the care of a physician and/or chiropractor and/or other qualified provider (see NOTE 3) for the diagnosis and/or condition which requires PT or OT services; AND
o A written plan of treatment approved by the patient's physician (or other qualified provider (see NOTE 3), relating the type, amount, frequency, and duration of the PT or OT services.
NOTE 2: Plan of care should be updated as the patient’s condition changes, and recertified by the qualified provider (see NOTE 3). A certification request must include all required plan of care elements. Certifications will be valid for either the number of treatments, the number of weeks, or the number of calendar days, whichever is longest. In no case will a certification be granted for more than 90 calendar days from the first treatment day under that certified treatment plan. Proposed therapy beyond a certification requires formal recertification. AND
o Reasonable expectation that PT or OT will achieve measurable improvement in the patient's condition in a reasonable and predictable period of time (usually four to six months); AND
o Written evidence demonstrating progress and effectiveness for ongoing PT or OT services.
NOTE 3: If a chiropractor or other qualified provider is the attending provider and will also administer the PT or OT treatment, he or she will prepare the written plan of treatment. In Montana, scope of licensure for physical therapists allows direct access, i.e., evaluation and treatment without a physician’s referral. Therefore, the physical therapist might be the qualified provider who will evaluate the patient, administer the treatment, and prepare the written plan of care. Oklahoma scope of licensure allows direct access, i.e., evaluation and treatment without a physician’s referral for 30 days.
Physical or manipulative therapy performed for maintenance rather than restoration is considered not medically necessary.
In addition to the above criteria, OT services that may be considered medically necessary include treatments that are expected to result in significant functional improvement, and are for the purpose of enabling the patient to perform activities of daily living.
OT services that consist of non-essential, self-help, or recreational tasks are considered not medically necessary, including training to facilitate reintegration into community and/or work environment (i.e., shopping, money management, educational and vocational activities, gardening, driving, etc.)
Physical Therapy in Water (i.e., aquatic therapy, aquatic rehabilitation)
Aquatic therapy may be considered medically necessary as with any other PT modality only when there is documentation in the patient's record that the therapy is administered one-to-one (not in a group) by a physical therapist, or other qualified licensed provider of physical therapy (as noted above).
Whirlpool bath, contrast bath, and Hubbard tank may be considered medically necessary as with any other physical therapy (PT) modality.
NOTE 4: Physical therapy in water is subject to the same contract and medical limitations and guidelines as any other form of physical therapy.
The following are considered not medically necessary:
• Aquatic aerobics and exercise programs that do not meet all the listed criteria;
• Group sessions such as exercise or aerobics classes that do not meet all the listed criteria;
• Separate charges for a pool or use of a pool.
Physical therapy for athletic training or athletic training evaluation that does not meet the criteria stated above is considered not medically necessary.
Physical therapy (PT) is the treatment of disease or injury using therapeutic exercise and other interventions that focus on improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, functional activities of daily living, and pain relief. Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiological principles.
Physical therapy services include therapeutic interventions tailored to the specific needs of the patient. Such interventions include therapeutic exercise programs to increase strength and endurance, as well as application of various other modalities including, but not limited to, heat, cold, electrical stimulation, ultrasound, hydrotherapy, and massage or mobilization techniques. These services must be rendered under a written plan of care established by a physician or other qualified non-physician practitioner (e.g., physician assistant), and must be performed by a licensed physical therapist, or by assistive personnel under the supervision of a licensed physical therapist; if performed by assistive personnel, such services shall not exceed his or her education, training and/or licensure. To be considered medically necessary, these modalities must also be proven and accepted as effective and/or safe for the treatment of disease or injury.
Durable condition-specific benefit is:
• A measurable improvement in or restoration of a functional impairment that resulted from a specific disease, trauma, congenital anomaly or therapeutic intervention; and
• Able to be sustained long-term without significant deterioration.
A few examples of measurable parameters include range of motion (ROM) measurements, wound measurements, distance the patient can ambulate, and amount of support the patient needs to ambulate.
A maintenance program consists of activities that preserve the patient’s present level of function and prevents regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Supportive therapy also refers to therapy that is needed to maintain or sustain level of function.
Aquatic therapy is therapeutic PT exercises taking place in or on water, most likely in a swimming pool. This involves the therapist doing manipulation, mobilization or manual stretching and strengthening in the water instead of on land. This type of therapy may be useful following intra-articular and ligament reconstruction in the knee, as well as for walking reeducation, strengthening leg muscles, and enhancing joint range of motion. Aquatic therapy may also be a beneficial form of patient treatment for rheumatic disease.
Whirlpool bath is a therapeutic bath in which all or part of the body is exposed to forceful whirling currents of hot water. Whirlpool bath may be used for debridement of traumatic wounds, burns, pressure ulcers or surgical wounds and as an adjunct means to achieve joint mobility.
Contrast bath is immersion of a part of the body alternately in hot and cold water.
Hubbard tank is a tank in which a patient may be immersed for the purpose of permitting him to perform underwater exercise.
Hydrotherapy is the application of water, in any form, but usually externally, in the treatment of disease. Any of the above listed forms of water baths or therapy could be called hydrotherapy.
Occupational therapy (OT) is a form of rehabilitation therapy involving the treatment of neuromusculoskeletal and psychological dysfunction through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual.
Occupational therapy involves cognitive, perceptual, safety, and judgment evaluations and training. These services emphasize useful and purposeful activities to improve neuromusculoskeletal functions and to provide training in activities of daily living (ADL). Activities of daily living include: feeding, dressing, bathing, and other self-care activities. Other occupational therapy services include the design, fabrication, and use of orthoses, and guidance in the selection and use of adapted equipment.
A search of peer reviewed literature through December 2017 identified few clinical trials that address the efficacy of specific physical therapy modalities or assess the effect of individual modalities in the treatment of specific conditions. The application of therapeutic modalities is generally based on empirical experience.
Physical therapy treatment consists of multiple modalities performed by licensed practitioners trained in the treatment of disorders of the muscles, bones, or joints. These services must meet certain criteria and be performed by a qualified provider in accordance with the requirements outlined by the American Physical Therapy Association (APTA) and the state licensure guidelines regarding scope of practice.
In 2011, the APTA published Practice Guidelines (5); a brief summary of the APTA patient/client management guideline follows:
• Perform an initial examination and evaluation to establish a diagnosis and prognosis prior to intervention.
• Establish a plan of care and manage the needs of the patient/client based on the examination, evaluation, diagnosis, prognosis, goals, and outcomes of the planned interventions for identified impairments, functional limitations, and disabilities.
• Provide or direct and supervise the physical therapy intervention consistent with the results of the examination, evaluation, diagnosis, prognosis, and plan of care.
• Reexamine the patient/client as necessary to evaluate progress or change in patient/client status and modify the plan of care accordingly, or discontinue physical therapy services.
• Discharge the patient/client from physical therapy services when the anticipated goals or expected outcomes for the patient/client have been achieved.
Direct access to physical therapy enables a patient to receive evaluation and/or treatment from a physical therapist without a physician’s referral. In January 2015, the APTA published a summary of direct access by state, based on each state’s licensure laws.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
The following codes may be applicable to this Medical policy and may not be all inclusive.
97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172, 97530, 97535, 97537, 97750, 97755, 97799, 98925, 98926, 98927, 98928, 98929, [Deleted 1/2017: 97001, 97002, 97003, 97004, 97005, 97006]
G0151, G0152, G0157, G0158, G0159, G0160, S8990
ICD-9 Diagnosis Codes
Refer to the ICD-9-CM manual
ICD-9 Procedure Codes
Refer to the ICD-9-CM manual
ICD-10 Diagnosis Codes
Refer to the ICD-10-CM manual
ICD-10 Procedure Codes
Refer to the ICD-10-CM manual
The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.
The Centers for Medicare and Medicaid Services (CMS) does not have a national Medicare coverage position. Coverage may be subject to local carrier discretion.
A national coverage position for Medicare may have been developed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.
1. Department of Health and Human Services, Office of Inspector General, Physical Therapy in the Physician's Office, March 1994. Available at <https://oig.hhs.gov> (accessed December 28, 2017)
2. Shankowsky H, Callioux L, Tredget E. North American Survey of Hydrotherapy in Modern Burn Care. J Burn Care Rehabil. 1994 Mar-Apr; 15(2):143-6. PMID: 8195254
3. Tovin BJ, Wolf SL, Greenfield BH, et al. Comparison of the Effects of Exercise in Water and on Land on the Rehabilitation of Patients with Intra-articular Anterior Cruciate Ligament Reconstructions. Phys Ther. 1994 Aug; 74(8):710-9. PMID: 8047560
4. Kelly BT, Roskin L, Kirkendall DT, et al. Shoulder muscle activation during aquatic and dry land exercises in non-impaired subjects. J Ortho Sports Phys Ther. 2000 Apr; 30(4):204-10. PMID: 10778797
5. Today’s physical therapist: A comprehensive review of a 21st-century health care professional. Appendix F Standards of Practice for Physical Therapy. APTA House of Delegates Standard S06-03-09-10. Prepared by the American Physical Therapy Association. January 2011; p 58-60. Available at <www.apta.org> (accessed December 14, 2017).
6. Physical Therapy—Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2002 April) Therapy 8.03.02.
7. Occupational Therapy—Archived. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2004 November—Archived) Therapy 8.03.03.
8. Centers for Medicare and Medicaid Services. Medicare Benefit Policy Manual Chapter 15 – Covered Medical and Other Health Services. Section 220 Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy and Speech-Language Pathology services) Under Medical Insurance. (Rev. 194, issued: 09-03-14) Available at <https://www.cms.gov> (accessed December 18, 2017)
9. Lima TB, Dias JM, Mazuquin BF, et al. The effectiveness of aquatic physical therapy in the treatment of fibromyalgia: a systematic review with met-analysis. Clin Rehabil. 2013 Oct; 27(10):892-908. PMID:23818412
10. Shamliyan TA, Wang SY, Olson-Kellogg B, et al. Physical Therapy Interventions for Knee Pain Secondary to osteoarthritis [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (U.S.); 2012 Nov. Report No.:12(13)-EHC115-EF. AHRQ Comparative Effectiveness Reviews. PMID: 23213666
11. Bennell KL, Egerton T, Martin J, et al. Effect of physical therapy on pain and function in patients with hip osteoarthritis: a randomized clinical trial. JAMA. 2014 May21; 311(19):1987-97. PMID: 24846036
|7/1/2018||Document updated with literature review. The following changes were made to Coverage: 1) Removed “restore acute loss of” and replaced with “improve” in the following statement: “ Is reasonably expected to improve function to an individual who suffers from functional impairment due to disease, trauma, congenital anomalies, or prior therapeutic intervention”; 2) Removed Montana, State Legislation mandates statement and replaced with * CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT *.|
|1/1/2017||Reviewed. No changes.|
|4/1/2015||Document updated with literature review. The following was added to Coverage: 1) Terminology was modified so that “qualified provider” either replaced “physician”, or was added along with “physician”; 2) Physical or manipulative therapy performed for maintenance rather than restoration is considered not medically necessary; 3) Information was added to the NOTE (about qualified providers) regarding direct access to PT care without a physician’s referral; 4) Language stating coverage of PT in water is allowed/not allowed was changed to may be considered medically necessary/not medically necessary; 5) Recertification requirements were clarified and “every 30 days” was removed; 6) Requirements for certification and recertification were revised to be “ A certification request must include all required plan of care elements. Certifications will be valid for either the number of treatments, the number of weeks, or the number of calendar days, whichever is longest. In no case will a certification be granted for more than 90 calendar days from the first treatment day under that certified treatment plan. Proposed therapy beyond a certification requires formal recertification.”|
|4/15/2014||Document updated with literature review. Coverage unchanged.|
|8/1/2011||Coverage revised. The following statements were added: OT services that may be considered medically necessary include treatments that are expected to result in significant functional improvement, and are for the purpose of enabling the patient to perform activities of daily living. OT services that consist of non-essential, self-help, or recreational tasks are considered not medically necessary, including training to facilitate reintegration into community and/or work environment (i.e., shopping, money management, educational and vocational activities, gardening, driving, etc.)|
|1/1/2010||CPT/HCPCS code(s) updated, medical policy unchanged|
|11/1/2009||Policy was edited to clarify that Occupational Therapy (OT) providers may also be providers of Physical Therapy Services, and that this policy does apply to OT providers. Policy title was revised to include OT.|
|4/1/2008||Policy reviewed without literature review; new review date only.|
|3/15/2006||Revised/updated entire document|
|10/1/2004||CPT/HCPCS code(s) updated, medical policy unchanged|
|1/1/2002||Revised/updated entire document. CPT/HCPCS code(s) updated, medical policy unchanged|
|6/1/2001||CPT/HCPCS code(s) updated, medical policy unchanged|
|5/1/2000||Revised/updated entire document|
|11/1/1999||CPT/HCPCS code(s) updated, medical policy unchanged|
|9/1/1999||CPT/HCPCS code(s) updated, medical policy unchanged|
|1/1/1998||Revised/updated entire document|
|5/1/1996||Revised/updated entire document|
|10/1/1994||Revised/updated entire document|
|9/1/1990||New Medical Document|
|Title:||Effective Date:||End Date:|
|Physical Therapy (PT) and Occupational Therapy (OT) Services||01-01-2017||06-30-2018|
|Physical Therapy (PT) and Occupational Therapy (OT) Services||04-01-2015||12-31-2016|
|Physical Therapy (PT) and Occupational Therapy (OT) Services||04-15-2014||03-31-2015|
|Physical Therapy (PT) and Occupational Therapy (OT) Services||08-01-2011||04-14-2014|
|Physical Therapy (PT) and Occupational Therapy (OT) Services||01-01-2010||07-31-2011|
|Physical Therapy (PT) and Occupational Therapy (OT) Services||11-01-2009||12-31-2009|
|Physical Therapy (PT) Services||04-01-2008||10-31-2009|
|Physical Therapy (PT) Services||08-15-2006||03-31-2008|
|Physical Therapy (PT) Services||03-15-2006||08-14-2006|
|Information on Physical Therapy||01-01-2002||03-14-2006|
|Physical Therapy Administered in Water||09-01-1996||03-14-2006|