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 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.
Rehabilitation Services for Vision Impairment – Partial or complete vision loss may make therapy to improve activities of daily living reasonable and necessary.
Maintenance Therapy
Coverage of skilled rehabilitation services is contingent upon beneficiary’s need for skilled care whether the goals of therapy include maintenance or improvement.
Restorative/Rehabilitative Therapy
Restorative/rehabilitative therapy has the purpose of improving function or reversing loss of function.
General Physical Therapy Guidelines
A beneficiary must require the services of a skilled physical therapist for the service to be covered. The pressing need for a service, or the lack of availability of unskilled personnel to render the service with the necessary frequency does not itself make a service skilled. However, some services that would not normally be considered skilled therapy, may require the skilled services of a therapy professional care because of a special complicating medical factor. This must be clearly evident in the medical record.
SPECIFIC PROCEDURE AND MODALITY GUIDELINES:
FABRICATION/APPLICATION OF SPLINTS AND STRAPPING
1. Fabrication and application (as appropriate) of splints and strapping (e.g., the use of elastic wraps, heavy cloth and adhesive tape) are used to enhance performance of tasks or movements, support weak or ineffective joints or muscles, reduce/correct joint limitations/deformities, and/or protect body parts from injury. Splints and strapping are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of a patient’s needs and social/cultural environments.
2. The physical therapist targets the problems in performance of movements or tasks. The physical therapist may select (or fabricate) the most appropriate device or equipment, fit it and train the patient and/or caregiver(s) in its use and application. The goal is for the patient to function at a higher level by decreasing functional limitations.
3. The simple application of a commercial splint or brace will not be considered in this section.
Application 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 of thorax
May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, 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 and wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, 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, sprains/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissues.
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 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
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 Biofeedback Therapy and §30.1.1 Biofeedback Therapy for the Treatment of Urinary Incontinence.
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
Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk
For extremity manual muscle testing, 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
Manual testing of hands only.
Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands or including hand
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.
PT Evaluation and PT Re-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 at the start of therapy or when the beneficiary’s condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. 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 review,
c. Tests and measures,
d. Current functional status (abilities and deficits), and
e. Evaluation of patient’s, physician’s, and as appropriate the caregiver’s goals.
2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, the patient’s overall physical and cognitive health status, social/cultural supports, psychosocial factors and use of adaptive equipment. 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, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment.
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 considered reasonable and necessary when the beneficiary’s condition changes or treatment needs change so as to potentially warrant a new plan of care or a change to an existing plan of care. Some regulations and state practice acts require re-evaluation at specific intervals.
5. Re-evaluations are appropriate periodically to assess progress toward goals established in the plan of treatment, or to identify and establish interventions for newly developed impairments at least once every 30 days, for each therapy discipline.
Maintenance Programs
A maintenance program is a program designed to help a beneficiary maintain an existing level of function or minimize a loss of function. Coverage of skilled rehabilitation services is contingent upon beneficiary’s need for skilled care whether the goals of therapy include maintenance or improvement.
Hot or Cold Packs Therapy
1. 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 for sub-acute or chronic painful conditions.
2. Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not reasonable and necessary and therefore, are not covered.
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 on the use of a lymphedema pump for home use
Note: Further treatment of lymphedema by a physical therapist after the educational visits are generally not reasonable and necessary. Generally, education can be completed in 3 visits.
Paraffin Bath
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 alone do not typically make the skills of a therapist reasonable and necessary. However, heat treatments in the presence of a complicating medical factor may make the skills of a therapist reasonable and necessary.
Whirlpool
1. 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.
Diathermy Treatment
The coverage criteria and definition of diathermy treatment is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.5 Diathermy Treatment and Part 4, §240.3 Heat Treatment.
Infrared Therapy
The coverage criteria and definition of infrared therapy is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.6 Infrared Therapy Devices.
Electrical Stimulation Therapy
Electrical Nerve Stimulation (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.
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 Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds.
Contrast Bath Therapy
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 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.
Ultrasound (US) Therapy
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, US therapy 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 require that the services be rendered under the supervision of a qualified physical therapist.
3. Therapeutic exercises and neuromuscular re-education 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 treatment plans.
5. Requires (1-on-1) direct patient contact
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 and strengthening).
2. 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 activities of daily living training, or re-education
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 Re-education
1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, BAP’s boards, and desensitization techniques).
2. Neuromuscular re-education 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.
Gait Training Therapy
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 ambulation re-education
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 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.
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 affected muscles
d. The patient having abnormal adherence of tissue to surrounding tissue
e. The patient requiring relaxation in preparation for neuromuscular re-education 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 physical therapy interventions
Orthotics Training
1. This procedure may be considered reasonable and necessary if there is an indication for education on the application of the orthotic, the orthotic is in the home and the functional use of the orthotic is documented.
2. Generally, orthotic training can be completed in three 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 or self-care/home management 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 use the device.
Prosthetic Training
1. This procedure may be considered reasonable and necessary if there is an indication for education on the application of the prosthesis, the prosthesis is in the home and the functional use of the prosthetic is 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 or self-care/home management training.
3. Periodic revisits beyond the third month would require documentation to support medical necessity.
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 treatment plan 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 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 and definition 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 Institutional and Home Care Patient Education Programs.
Community/Work Reintegration
PT 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 section 1862(a)(1)(A) of the Social Security Act.
Wheelchair Management Training
1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who are wheelchair bound 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 qualified physical therapist and is designed to address specific needs of the patient. This training must be part of an active treatment plan 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.
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 patients response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient’s need for padding, underwrap, or socks and determining the patient’s tolerance to any dynamic forces being applied.
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 treatment plan, 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.
