Although there is an overlap in services provided by physical and occupational
therapists, this policy addresses only physical therapy (PT).  
  
PT services are part of a constellation of rehabilitative services designed to
improve or restore physical functioning, as well as, to prevent injury,
impairments, activity limitations, participation restrictions and disability
following disease, injury or loss of a body part. Impairments, activity
limitations and disabilities are addressed by the examination, evaluation and
development of a plan of care (POC) that may include implementation of
therapeutic interventions tailored to the specific needs of the individual
patient to achieve specific goals and outcomes. The specific interventions
that may be utilized are therapeutic exercises to strengthen muscles, maintain
or restore motion, integumentary repair and protection techniques, physical
agents and mechanical modalities, such as heat, cold, electrotherapeutic
modalities, ultrasound (US) and hydrotherapy, manual therapy and functional
training or retraining an individual to perform the activities of daily living
(ADLs).  
  
All PT services must be performed by or under the supervision of a qualified
physical therapist.  
  
For the purposes of this Local Coverage Determination (LCD), the
descriptions/definitions of supervision are those given in 42 CFR
410.32(b)(3).  
  
Qualified Physical Therapist: An individual who is licensed as a physical
therapist and meets the practice requirements in the state where they are
practicing.  
  
For outpatient settings, references to "physicians" throughout this policy
include nonphysician practitioners (NPPs), such as nurse practitioners,
clinical nurse specialists and physician assistants. Such NPPs may certify,
order and establish the POC for services by physical therapists as authorized
by state law.  
  
A qualified physical therapist, for program coverage purposes, is defined as
an individual who is licensed as a physical therapist and meets the practice
requirements in the state where they are practicing. Physiatrists, physicians
or NPPs, and qualified physical therapists have the knowledge, training, and
experience required to evaluate and, as necessary, re-evaluate a patient's
level of function, and determine whether a PT program could reasonably be
expected to improve, restore or compensate for lost function. Where
appropriate, the physical therapist can recommend to the physician or NPP a
POC. While the skills of a qualified physical therapist are required to
evaluate the patient's level of function and develop a POC, implementation of
the plan may also be carried out by a qualified physical therapy assistant
(PTA) functioning under the general supervision of the qualified physical
therapist.

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

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

**Restorative/Rehabilitative therapy:**  
  
In evaluating a claim for skilled therapy that is restorative/rehabilitative
(i.e., whose goal and/or purpose is to reverse, in whole or in part, a
previous loss of function), it would be entirely appropriate to consider the
beneficiary's potential for improvement from the services.  
  
 **Maintenance therapy:**  
  
A maintenance program is a program designed to maintain or to slow
deterioration as described in the CMS Internet-Only Manual Pub. 100-02,
Medicare Benefit Policy Manual, Chapter 15, 220 and 220.2 and must meet
these criteria to be considered reasonable and necessary.  
  
 **GENERAL PT GUIDELINES**  
  
1\. PT services are covered services provided the services are of a level of
complexity and sophistication, or the patient's condition is such that the
services can be safely and effectively performed only by a licensed physical
therapist or under his/her supervision. Services normally considered a routine
part of nursing care are not covered as PT (i.e., turning patients to prevent
pressure injuries, walking a patient in the hallway postoperatively or
ambulation without gait training).  
  
2\. Covered PT must be furnished while the individual is or was under the care
of a physician. Services must relate directly and specifically to a written
plan of treatment regimen established by the physician or NPP after any
necessary consultation with the qualified physical therapist, or by the
physical therapist providing the services and must be reasonable and necessary
to the treatment of the individual's illness or injury.  
  
3\. In order for the plan of treatment to be covered, it must address a
condition for which PT is an accepted method of treatment as defined by
standards of medical practice. Also, the plan of treatment must be for a
condition that is expected to improve significantly within a reasonable and
generally predictable period of time or establishes a safe and effective
maintenance program. If at any point in the treatment of an illness it is
determined that the treatment is not rehabilitative or does not legitimately
require the services of a qualified professional for management of a
maintenance program, the services will no longer be considered reasonable and
necessary and are excluded from coverage.  
  
4\. PT is only covered when it is rendered under a written plan of treatment
established by the physician, NPP or the qualified physical therapist, to
address specific therapeutic goals for which modalities and procedures are
planned out specifically in terms of type, frequency and duration. The
physician or NPP should periodically review the plan of treatment.  
  
5\. The physician or NPP and/or therapist must document the patient's
functional limitations in terms that are objective and measurable.  
  
 **SPECIFIC PROCEDURE AND MODALITY GUIDELINES**  
  
 **Computerized Dynamic Posturography**  
  
Computerized dynamic posturography is a "quantitative method for assessing
balance functioning under various simulated tasks. Protocols are designed to
test the sensory, motor and biomechanical components of balance individually
and in concert." Computerized dynamic posturography "may assist with lesion
localization, identifying adaptive strategies and functional capabilities."  
  
 ***Note:** Results of computerized dynamic posturography must be used in
determining the patient centered POC.  
  
 **Wound Care Selective  **  
  
 **a) Debridement:**  
  
Debridement is indicated whenever necrotic tissue is present on a documented
open wound. Debridement may also be indicated in cases of abnormal wound
repair.  
  
**b) Conservative Sharp Debridement:**  
  
Conservative sharp debridement is a minor procedure that requires no
anesthesia and is performed on an outpatient basis. Scalpel, scissors, and
forceps may be used and only clearly identified devitalized tissue is removed.
Generally, there is no specific bleeding associated with this procedure.  
  
 **Wound(s) Care Non-Selective Debridement  and Negative Pressure Wound
Therapy **  
  
 **a) Enzymatic Debridement:**  
  
Debridement with topical enzymes is used when necrotic substances to be
removed from a wound are protein, fibrin and collagen. The manufacturer's
product insert contains indications, contraindications, precautions, dosage,
and administration. It would be the clinician's responsibility to comply with
the product insert/guidelines.  
  
 **b) Autolytic Debridement:**  
  
This type of debridement is indicated where manageable amounts of necrotic
tissue are present, and there is no infection. Autolytic debridement occurs
when the enzymes that are naturally found in wound fluids are sequestered
under synthetic dressings. Autolytic debridement is contraindicated for wounds
that contain infection.  
  
 **c) Mechanical Debridement:**  
  
Wet-to-moist dressings may be used with wounds that have a high percentage of
necrotic tissue. Wet-to-moist dressings should be used cautiously as
maceration of surrounding tissue may hinder healing.  
  
Hydrotherapy and wound irrigation are also forms of mechanical debridement
used to remove necrotic tissue. They also should be used cautiously, as
maceration of surrounding tissue may hinder healing.  
  
 **d) Negative Pressure Wound Therapy:**  
  
Negative Pressure Wound Therapy is a non-invasive treatment by which
controlled localized negative pressure is delivered to a wide variety of
acute, sub-acute, and chronic wounds. Negative Pressure Wound Therapy should
be used cautiously as maceration of surrounding tissue may hinder healing.  
  
 **Fabrication/Application of Casts, Splints and Strapping**  
  
Fabrication and application of casts, splints, and strapping (e.g., the use of
elastic wraps, heavy cloth, adhesive tape) will be considered reasonable and
necessary if used to support weak or ineffective joints/muscles,
reduce/correct joint limitations/deformities and/or protect body parts from
injury, thus enhancing the performance of tasks or movements. The casts,
splints and strapping are often used in conjunction with therapeutic exercise,
functional training, and other interventions and should be selected in the
context of patient needs and social/culture environments.  
  
 **BODY AND UPPER EXTREMITY CASTS**  
  
 **Application of long arm cast**  
  
May be indicated for the shoulder and/or elbow in the treatment of fractures,
dislocations, sprains/strains, tendonitis, post-op reconstruction,
contractures and/or other deformities involving soft tissue.  
  
 **Application of short arm cast**  
  
May be indicated for the forearm, wrist and/or hand in the treatment of
fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction,
contractures or other deformities involving soft tissue.  
  
 **Application of hand and lower forearm cast**  
  
May be indicated for the forearm, wrist and/or hand in the treatment of
fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction,
contractures or other deformities involving soft tissue.  
  
 **SPLINTS**  
  
 **Application of long arm splint**  
  
May be indicated for the shoulder and/or elbow in the treatment of fractures,
dislocations, sprains/strains, tendonitis, post-op reconstruction,
contractures or other deformities involving soft tissue.  
  
 **Application of short arm splint**  
  
May be indicated for the forearm, wrist and/or hand in the treatment of
fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction,
contractures or other deformities involving soft tissue.  
  
 **Application of finger splint**  
  
May be indicated for the finger in the treatment of fractures, dislocations,
sprains/strains, tendonitis, post-op reconstruction, contractures or other
deformities involving soft tissue.  
  
 **STRAPPING-ANY AGE**  
  
 **Strapping of thorax**  
  
May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal
musculature in the treatment of contusions, dislocations, fractures,
sprains/strains, post-op conditions, neuromuscular conditions, contractures or
other deformities involving soft tissue.  
  
 **Strapping of low back  **  
  
May be indicated for the lumbar spine, rib cage or abdominal musculature in
the treatment of contusions, dislocations, fractures, sprains/strains, post-op
conditions, neuromuscular conditions, contractures or other deformities
involving soft tissue.  
  
 **Strapping of shoulder (e.g., Velpeau)**  
  
May be indicated for any portion of the shoulder girdle complex, or rib cage
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, neuromuscular conditions, contractures or other
deformities involving soft tissue.  
  
 **Strapping of elbow or wrist  **  
  
May be indicated for the elbow or wrist when there is involvement of the
humerus, forearm, wrist or hand in the treatment of contusions, dislocations,
fractures, sprains/strains, post-op conditions, neuromuscular conditions,
edema, scar management, contractures or other deformities involving soft
tissue.  
  
 **Strapping of hand or finger**  
  
May be indicated when there is involvement of the hand or finger(s) in the
treatment of contusions, dislocations, fractures, sprain/strains, post-op
conditions, neuromuscular conditions, edema, scar management, contractures or
other deformities involving soft tissue.  
  
 **LOWER EXTREMITY CASTS**  
  
 **Application of long leg cast**  
  
May be indicated when there is involvement of the femur, patella, tibia,
fibula, ankle or foot in the treatment of contusions, dislocations, fractures,
sprains/strains, post-op conditions, contractures or other deformities
involving soft tissue.  
  
 **Application of short leg cast**  
  
May be indicated when there is involvement of the tibia, fibula, ankle or foot
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, contractures or other deformities involving soft tissue.  
  
 **Application of rigid leg cast**  
  
May be indicated for recent amputees or patients with lower extremity ulcers.  
  
 **SPLINTS**  
  
 **Application of long leg splint**  
  
May be indicated when there is involvement of the femur, patella, tibia,
fibula, ankle or foot in the treatment of contusions, dislocations, fractures,
sprains/strains, post-op conditions, contractures or other deformities
involving soft tissue.  
  
 **Application of short leg splint**  
  
May be indicated when there is involvement of the tibia, fibula, ankle or foot
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, contractures or other deformities involving soft tissue.  
  
 **STRAPPING-ANY AGE**  
  
 **Strapping of hip**  
  
May be indicated when there is involvement of the lower back, abdomen or hip
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, neuromuscular conditions, contractures or other
deformities involving soft tissue.  
  
 **Strapping of knee**  
  
May be indicated when there is involvement of the thigh, knee, or lower leg in
the treatment of contusions, dislocations, fractures, sprains/strains, post-op
conditions, neuromuscular conditions, contractures or other deformities
involving soft tissue.  
  
 **Strapping of ankle and/or foot**  
  
May be indicated when there is involvement of the lower leg, ankle and/or foot
in the treatment of contusions, dislocations, fractures, sprains/strains,
post-op conditions, neuromuscular conditions, contractures or other
deformities involving soft tissue.  
  
 **Strapping of toes**  
  
May be indicated when there is involvement of any of the toes in the treatment
of contusions, dislocations, fractures, sprains/strains, post-op conditions,
neuromuscular conditions, contractures or other deformities involving soft
tissue.  
  
 **Application of unna boot**  
  
A dressing for ulcers resulting from venous insufficiency, consisting of a
paste made from gelatin zinc oxide and glycerin, which is applied to the leg,
then covered with a spiral bandage, this in turn being given a coat of the
paste. The process is repeated until satisfactory rigidity is attained.  
  
 **Biofeedback training any method and biofeedback training perineal muscles,
anorectal or urethral sphincter including EMG and/or manometry  **  
  
The coverage criteria and definition of biofeedback therapy is found in the
CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage
Determinations Manual, Chapter 1, Part 1, 30.1 and 30.1.1.  
  
"Biofeedback is a tool utilized by physical therapists to assist with muscle
training. This includes facilitation of muscles that are demonstrating
suboptimal performance as well as relaxation of muscles that may be inhibiting
coordinated movement. Biofeedback can be visual or auditory."  
  
 **Muscle testing, manual**  
  
Manual testing of muscle groups for strength are based on grading scales.  
  
 **Muscle testing, manual (separate procedure) with report; extremity
(excluding hand) or trunk  **  
  
Every muscle of at least 1 extremity would need to be tested, with
documentation of why such a thorough assessment was warranted.  
  
 **Muscle testing, manual (separate procedure) with report; hand, with or
without comparison with normal side  **  
  
 **Muscle testing, manual (separate procedure) with report; total evaluation
of body, excluding hands or including hands**  
  
The measurement of muscle performance using manual muscle testing only.  
  
 **Range of Motion (ROM) Measurements**  
  
Determination of ROM using a tape measure, flexible ruler, electronic device
or goniometer.  
  
Every joint of an extremity would need to be tested, with documentation of why
such a thorough assessment was warranted.  
  
 **PT Evaluation**  
  
Evaluation is a comprehensive service that requires professional skills to
make clinical judgments about conditions for which services are indicated
based on objective measurements and subjective evaluations of patient
performance and functional abilities. Evaluation is warranted, e.g., for a new
diagnosis or when a condition is treated in a new setting. These evaluative
judgments are essential to development of the POC, including goals and the
selection of interventions. The time spent in evaluation does not count as
treatment time.  
  
1\. The initial examination has the following components:

 a. The patient history to include prior level of function  
  
 b. Relevant systems reviews  
  
 c. Tests and measures  
  
 d. Current functional status (abilities and deficits)

2\. Factors that influence the complexity of the examination and evaluation
process include the clinical findings, extent of loss of function, social
considerations, and the patient's overall physical function and health status.
Thus, the evaluation reflects the chronicity or severity of the current
problem, the possibility of multi-site or multi-system involvement, the
presence of preexisting systemic conditions or diseases, and the stability of
the condition. Physical therapists also consider the level of the current
impairments and the probability of prolonged impairment, functional
limitation, disability, the living environment, and the social supports.  
  
3\. Initial evaluations or re-evaluations may be determined reasonable and
necessary even when the evaluation determines that skilled rehabilitation is
not required if the patient's condition showed a need for an evaluation, or
even if the goals established by the plan of treatment are not realized.  
  
4\. Re-evaluation is periodically indicated during an episode of care when the
professional assessment indicates a significant improvement or decline in the
patient's condition or functional status. Some regulations and state practice
acts require re-evaluation at specific intervals. A re-evaluation is focused
on evaluation of progress toward current goals and making a professional
judgment about continued care, modifying goals, and/or treatment or
terminating services.  
  
5\. A re-evaluation may be appropriate prior to a planned discharge for the
purposes of determining whether goals have been met, or for the use of the
physician or the treatment setting at which treatment will be continued.  
  
 **MAINTENANCE PROGRAMS**  
  
A maintenance program is a program intended to maintain function or slow the
decline in function. Coverage of skilled rehabilitation services is contingent
upon a beneficiary's need for skilled care. When a program to maintain or
reduce decline in functional status requires the skills of a licensed
therapist to be performed safely and effectively, provision of skilled
services for the execution of that therapy program is covered. The skilled
need must come from the nature of the service being rendered and the patient's
unique circumstance. The provision of therapy services by skilled personnel
does not in itself make the service one that requires skilled care.  
 ** **  
 **Hot or Cold Packs Therapy**

Hot or cold packs are used primarily in conjunction with therapeutic
procedures to provide analgesia, relieve muscle spasm and reduce inflammation
and edema. Typically, cold packs are used for acute, painful conditions, and
hot packs are used for subacute or chronic painful conditions.  
  
 **Mechanical Traction Therapy**  
  
1\. Traction is generally limited to the cervical or lumbar spine with the
hope of relieving pain in or originating from those areas.  
  
2\. Specific indications for the use of mechanical traction include:

 a. Cervical and/or lumbar radiculopathy  
  
 b. Back disorders, such as disc herniation, lumbago, and sciatica

**Vasopneumatic Device Therapy**  
  
1\. The use of vasopneumatic devices may be considered reasonable and
necessary for the application of pressure to an extremity for the purpose of
reducing edema.  
  
2\. Specific indications for the use of vasopneumatic devices include:

a. Reduction of edema after acute injury  
  
b. Lymphedema of an extremity  
  
c. Education and training on the use of vasopneumatic devices for home use

**Note:** Further treatment on the use of vasopneumatic devices by physical
therapists, after the education and training visits, is usually not reasonable
and necessary. Generally, education and training can be completed in 3 visits.  
  
 **Paraffin Bath Therapy**  
  
1\. Paraffin bath, also known as hot wax treatment, is primarily used for pain
relief in chronic joint problems of the wrists, hands, and feet.  
  
2\. Heat treatments of this type do not ordinarily require the skills of a
qualified physical therapist. However, in a particular case, the skills,
knowledge and judgment of a qualified physical therapist might be required in
such treatments or baths, _e_.g., where the patient's condition is complicated
by circulatory deficiency, areas of desensitization, open wounds, fractures,
or other complications. Also, if such treatments are given prior to but as an
integral part of a skilled PT procedure, they would be considered part of the
PT service.  
  
 **Whirlpool Therapy/Hubbard Tank**  
  
1\. Heat treatments of this type and whirlpool baths do not ordinarily require
the skills of a qualified physical therapist. However, in a particular case,
the skills, knowledge and judgment of a qualified physical therapist might be
required in such treatments or baths, e.g., where the patient's condition is
complicated by circulatory deficiency, areas of desensitization, open wounds,
fractures, or other complications. Also, if such treatments are given prior to
but as an integral part of a skilled PT procedure, they would be considered
part of the PT service.  
  
2\. Whirlpool bath and Hubbard Tanks are the most common forms of
hydrotherapy. The use of whirlpool is considered reasonable and necessary when
used as part of a plan directed at facilitating the healing of an open wound
(e.g., burns).  
  
3\. Specific indications for the use of whirlpools include the following:

a. The patient having a documented open wound which is draining, has a foul
odor, or evidence of necrotic tissue  
  
b. The patient having a documented need for wound debridement/bandage removal  
  
c. Exfoliative skin impairments

**Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders (Dry
Whirlpool)**  
  
The coverage criteria and definition of fluidized therapy dry heat (dry
whirlpool) are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare
National Coverage Determinations Manual, Chapter 1, Part 2, 150.8.  
  
 **Diathermy Treatment**  
  
Diathermy coverage criteria and definition are found in the CMS Internet-Only
Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter
1, Part 2, 150.5 and Part 4, 240.3.  
  
 **Infrared Therapy Devices**  
  
Noncoverage of Infrared Therapy Devices is described in the CMS Internet-Only
Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter
1, Part 4, 270.6.  
  
**Ultraviolet Therapy**  
  
The application of ultraviolet therapy is considered reasonable and necessary
for the patient requiring the application of a drying heat. The specific
indications for this therapy are as follows:

a. A patient having an open wound; minimal erythema  
  
b. Severe psoriasis limiting ROM

**Electrical Stimulation Therapy**  
  
"Visual, verbal and/or manual contact "(i.e., constant attendance) when 1-on-1
instruction is required for subsequent home use of a Transcutaneous Electrical
Nerve Stimulation (TENS) unit.  
  
TENS is not reasonable and necessary for the treatment of Chronic Low Back
Pain (CLBP) under 1862(a)(1)(A) of the Social Security Act.  
  
 **Electrical Stimulation (ES) Therapy-Unattended**  
  
Electrical stimulation therapy and definition are found in the CMS Internet-
Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual,
Chapter 1, Part 4, 270.1.  
  
 **Electromagnetic Therapy**  
  
Electromagnetic therapy criteria and definition are found in the CMS Internet-
Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual,
Chapter 1, Part 4, 270.1.  
  
 **Iontophoresis Application**  
  
1\. Iontophoresis is a process in which electrically charged molecules or
atoms (i.e., ions) are driven into tissue with an electrical field. Voltage
provides the driving force. Parameters such as, drug polarity and
electrophoretic mobility must be known in order to be able to assess whether
iontophoresis can deliver therapeutic concentrations of a medication at sites
below the skin.  
  
2\. The application of iontophoresis is considered reasonable and necessary
for the topical delivery of medications into a specific area of the body.  
  
3\. Specific indications for the use of iontophoresis application include:

a. The patient having tendonitis or calcific tendonitis  
  
b. The patient having bursitis  
  
c. The patient having adhesive capsulitis  
  
d. The patient having hyperhidrosis  
  
e. Thick adhesive scar(s)

**Contrast Baths**  
  
1\. Contrast baths are a special form of therapeutic heat and cold that can be
applied to distal extremities. The effectiveness of contrast baths is thought
to be due to reflex hyperemia produced by the alternating exposure to heat and
cold. Although a variety of applications are possible, contrast baths often
are used in treatment to decrease edema and inflammation.  
  
2\. The use of contrast baths is considered reasonable and necessary to
desensitize patients to pain by reflex hyperemia produced by the alternating
exposure to heat and cold.  
  
3\. Specific indications for the use of contrast baths include:

a. The patient having rheumatoid arthritis or other inflammatory arthritis  
  
b. The patient having reflex sympathetic dystrophy  
  
c. The patient having a sprain or strain resulting from an acute injury

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

1\. Therapeutic US is a deep heating modality that produces a sound wave of
0.8 to 3.0 MHz. In the human body, US has several pronounced effects on
biologic tissues. It is attenuated by certain tissues and reflected by bone.
Thus, tissues lying immediately next to bone can receive an even greater
dosage of US, as much as 30% more. Because of the increased extensibility US
produces in tissues of high collagen content, combined with the close
proximity of joint capsules, tendons, and ligaments to cortical bone where
they receive a more intense irradiation, it is an ideal modality for
increasing mobility in those tissues with restricted ROM.  
  
2\. The application of US is considered reasonable and necessary for patients
requiring deep heat to a specific area for reduction of pain, spasm, and joint
stiffness, and the increase of muscle, tendon and ligament flexibility.  
  
3\. Specific indications for the use of US application include:

a. The patient having tightened structures limiting joint motion that require
an increase in extensibility  
  
b. The patient having symptomatic soft tissue calcification  
  
c. The patient having neuromas

**Note:** US application is **not** considered to be reasonable and necessary
for the treatment of asthma, bronchitis or any other pulmonary condition.  
  
 **GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES**  
  
1\. Therapeutic procedures are procedures that attempt to reduce impairments
and improve function through the application of clinical skills and/or
services.  
  
2\. Use of these procedures requires that these services be rendered under the
supervision of a physical therapist.  
  
3\. Therapeutic exercises and neuromuscular reeducation are examples of
therapeutic interventions. The expected goals documented in the written plan
of treatment, effected by the use of each of these procedures, will help
define whether these procedures are reasonable and necessary. Therefore, since
any 1 or a combination of more than 1 of these procedures may be used in a
written plan of treatment, documentation must support the use of each
procedure as it relates to a specific therapeutic goal.  
  
4\. Services provided concurrently by a physical therapist and occupational
therapist may be covered, if separate and distinct goals are documented in the
written plan of treatment.  
  
5\. Require 1-on-1 direct patient contact, unless otherwise stated.  
  
 **Therapeutic Exercises**  
  
1\. Therapeutic exercise is performed with a patient either actively, active-
assisted, or passively participating (e.g., treadmill, isokinetic exercise,
lumbar stabilization, stretching, strengthening, continuous passive motion).  
  
2. Therapeutic exercise may address impairments of exercise tolerance due to cardiopulmonary impairments. Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.  
  
3\. Therapeutic exercise is considered reasonable and necessary if at least 1
of the following conditions is present and documented:  
  
    a. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint ROM, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance  
  
    b. The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, ROM, or endurance as part of ADLs training, or reeducation  
  
4\. Documentation for therapeutic exercise typically includes objective loss
of joint motion, strength, and/or mobility (e.g., degrees of motion, strength
grades, levels of assistance).  
  
 **Neuromuscular Reeducation**  
  
1\. This therapeutic procedure is provided to improve balance, coordination,
kinesthetic sense, posture, and proprioception (e.g., proprioceptive
neuromuscular facilitation, Biomechanical Ankle Platform [BAP's] boards, and
desensitization techniques).  
  
2\. Neuromuscular reeducation may be considered reasonable and necessary for
impairments, which affect the body's neuromuscular system (e.g., poor static
or dynamic sitting/standing balance, loss of gross and fine motor
coordination, tilt table or standing table, hypo/hypertonicity) and
improvement of motor control and motor learning.  
  
**Aquatic Therapy with Therapeutic Exercises**  
  
"Aquatic therapy describes therapeutic exercises performed in a water-based
environment. The properties and temperature of the water facilitate movement,
particularly for muscles that are compromised due to injury, surgery, or
disease (e.g., polio, rheumatoid arthritis, multiple sclerosis, joint
arthroplasty)." It is important for the physical therapist to document the
need for exercises performed in a water-environment vs land-based exercises.
There should be a plan for transitioning from water-based exercises to land-
based exercise.  
  
1\. This procedure uses the therapeutic properties of water (e.g., buoyancy,
resistance). The procedure may be reasonable and necessary for a loss or
restriction of joint motion, strength, or mobility (e.g., degrees or motion,
strength grades, levels of assistance).  
  
2\. Aquatic therapy with therapeutic exercise may be considered reasonable and
necessary in the treatment of the following conditions:

a. The patient having pain, joint stiffness or muscle spasms resulting from
rheumatoid arthritis  
  
b. The patient having had a cast removed or recent surgery and requiring
mobilization of limbs  
  
c. The patient having paraparesis or hemiparesis  
  
d. The patient having had a recent amputation  
  
e. The patient recovering from a paralytic condition  
  
f. The patient requiring limb mobilization after a head trauma  
  
g. The patient having the inability to tolerate exercise for rehabilitation
under gravity-based weight bearing  
  
h. The patient having fibromyalgia

**Gait Training**  
  
1\. This procedure may be reasonable and necessary for training patients whose
walking abilities have been impaired by neurological, muscular, or skeletal
abnormalities or trauma.  
  
2\. Specific indications for gait training include:

a. The patient having suffered a cerebral vascular accident resulting in
impairment in the ability to ambulate, now stabilized and ready to begin
rehabilitation  
  
b. The patient having recently suffered a musculoskeletal trauma requiring
gait reeducation  
  
c. The patient having a chronic, progressively debilitating condition, for
which safe ambulation has recently become a concern  
  
d. The patient having had an injury or condition that requires instruction in
the use of a walker, crutches, or cane  
  
e. The patient having been fitted with a brace/lower limb prosthesis/orthosis
and requires instruction in ambulation  
  
f. The patient having a condition that requires retraining in stairs/steps or
chair transfer in addition to general ambulation

3\. Gait evaluation and training furnished to a patient whose ability to walk
has been impaired by neurological, muscular or skeletal abnormality require
the skills of a qualified physical therapist and constitute skilled PT and are
considered reasonable and necessary, if they can be expected to materially
improve or maintain the patient's ability to walk or prevent or slow further
deterioration of the patient's ability to walk. Gait evaluation and training
which is furnished to a patient whose ability to walk has been impaired by a
condition other than a neurological, muscular, or skeletal abnormality would,
nevertheless, be covered where PT is reasonable and necessary to restore or
maintain function or to prevent or slow further deterioration.  
  
**Massage Therapy**  
  
1\. Massage is the application of systemic manipulation to the soft tissues of
the body for therapeutic purposes. Although various assistive devices and
electrical equipment are available for the purpose of delivering massage, use
of the hands is considered the most effective method of application, because
palpation can be used as an assessment, as well as, a treatment tool.  
  
2\. Massage therapy, including effleurage, petrissage, and/or tapotement
(stroking, compression, percussion) may be considered reasonable and necessary
if at least 1 of the following conditions is present and documented:

a. The patient having paralyzed musculature contributing to impaired
circulation  
  
b. The patient having sensitivity of tissues to pressure  
  
c. The patient having tight muscles resulting in shortening and/or spasticity
of affective muscles  
  
d. The patient having abnormal adherence of tissue to surrounding tissue  
  
e. The patient requiring relaxation in preparation for neuromuscular
reeducation or therapeutic exercise  
  
f. The patient having contractures and decreased ROM

3\. In most cases, postural drainage and pulmonary exercises can be carried
out safely and effectively by nursing personnel. To be considered for payment,
the physical therapist must identify the intervention that is best suited for
the patient, taking into consideration the patient's condition and any
contraindications that may be present. As there can be an overlap of skills
between disciplines, i.e., respiratory therapy, skilled nursing and PT, the
documentation must clearly support the need for the intervention to be
provided by the physical therapist.  
  
**Manual Therapy**  
  
1. **Joint Mobilization (Peripheral or Spinal)**  
  
This procedure may be considered reasonable and necessary if restricted joint
motion is present and documented. It may be reasonable and necessary as an
adjunct to therapeutic exercises when loss of articular motion and flexibility
impedes the therapeutic procedure.  
  
2. **Soft Tissue Mobilization**   
  
This procedure involves the application of skilled manual therapy techniques
(active or passive) to soft tissues in order to effect changes in the soft
tissues, articular structures, neural or vascular systems. Examples are
facilitation of fluid exchange, restoration of movement in acutely edematous
muscles, or stretching of shortened muscular or connective tissue.  
  
Soft tissue mobilization can be considered reasonable and necessary if at
least 1 of the following conditions is present and documented:

a. The patient having restricted joint or soft tissue motion in an extremity,
neck or trunk  
  
b. Treatment being a necessary adjunct to other PT interventions

3\. **Manipulation**  
  
This procedure may be considered reasonable and necessary for treatment of
painful spasm or restricted motion of soft tissues. It may also be used as an
adjunct to other therapeutic procedures.  
  
4\. **Manual Lymphatic Drainage/Complex Decongestive Therapy**  
  
The goal of this type of therapy is to reduce lymphedema by routing the fluid
to functional pathways, preventing backflow as the new routes become
established, and to use the most appropriate methods to maintain the reduction
after therapy is complete. This therapy involves intensive treatment to reduce
the size by a combination of manual decongestive therapy and serial
compression bandaging, followed by an exercise program.

a. It is expected that during these sessions, education is being provided to
the patient and/or caregiver on the correct application of the compression
bandage.  
  
b. It is also expected that after the completion of the therapy, the patient
and/or caregiver can perform these activities without supervision.

**Group Therapeutic Procedures**  
  
A group for the purpose of performing group therapy will be defined as:

a. Two or more patients per therapist receiving active therapy but not 1-on-1
treatment, and  
  
b. The patients may be performing the same exercise or a different exercise,
but the physical therapist is instructing all the patients in the group.

**Orthotic Training**  
  
1\. This procedure may be considered reasonable and necessary, if there is an
indication for education for the application of orthotics, and the functional
use of the orthotic is present and documented.  
  
2\. Generally, orthotic training can be completed in 3 visits; however, for
modification of the orthotic due to healing of tissues, change in edema, or
impairment in skin integrity, additional visits may be required.  
  
3\. The medical record should document the distinct treatments rendered when
orthotic training for a lower extremity is done during the same visit as gait
training.  
  
4\. The patient is capable of being trained to use the particular device
prescribed in an appropriate manner. In some cases, the patient may not be
able to perform this function, but a responsible individual can be trained to
apply the device.  
  
 **Prosthetic Training**  
  
1\. This procedure may be considered reasonable and necessary, if there is an
indication for education in the application of the prosthetic, and the
functional use of the prosthetic is present and documented.  
  
2\. The medical record should document the distinct goals and service rendered
when prosthetic training for a lower extremity is done during the same visit
as gait training.  
  
3\. Periodic revisits beyond the third month would require documentation to
support medical necessity.  
  
 **Orthotic/Prosthetic Checkout**  
  
1\. These assessments are reasonable and necessary for "established patients
who have already received the orthotic or prosthetic device (permanent or
temporary)."  
  
2\. These assessments may be reasonable and necessary when patients experience
a loss of function directly related to the device (e.g., pain, skin breakdown,
and falls).  
  
3\. These assessments may be reasonable and necessary for determining "the
patient's response to wearing the device, determining whether the patient is
donning/doffing the device correctly, determining the patient's need for
padding, under wrap, or socks and determining the patient's tolerance to any
dynamic forces being applied."  
  
 **Therapeutic Activities**  
  
1\. Therapeutic activities are considered reasonable and necessary for
patients needing a broad range of rehabilitative techniques that involve
movement. Movement activities can be for a specific body part or could involve
the entire body. This procedure involves the use of functional activities
(e.g., bending, lifting, carrying, reaching, catching and overhead activities)
to improve functional performance in a progressive manner. The activities are
usually directed at a loss or restriction of mobility, strength, balance, or
coordination. They require the skills of a physical therapist and are designed
to address a specific functional need of the patient. These dynamic activities
must be part of an active written POC and be directed at a specific outcome.  
  
2\. In order for therapeutic activities to be covered, the following
requirements must be met:

a. The patient having a condition for which therapeutic activities can
reasonably be expected to restore or improve functioning  
  
b. The patient's condition being such that he/she is unable to perform
therapeutic activities except under the direct supervision of a physician, NPP
or physical therapist  
  
c. There being a clear correlation between the type of exercise performed and
the patient's underlying medical condition for which the therapeutic
activities were prescribed

**Sensory Integrative Techniques  **  
  
"Sensory integrative techniques are interventions generally intended for the
pediatric and/or neurologically impaired populations. The focus of these
activities is to train the sensory systems to modulate the vast array of
incoming sensory stimuli. This is something that is normally performed without
apparent effort. Once the patient/client learns to block the extrasensory
'noise,' the important sensory input can be processed, and a coordinated motor
response can be generated."  
  
 **Self-Care/Home Management Training**  
  
The coverage criteria of self-care management training is found in the CMS
Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations
Manual, Chapter 1, Part 3, 170.1.  
  
"Self-care/home management training describes a group of interventions that
focuses on ADL skills and compensatory activities needed to achieve
independence" or adapt to an evolving deterioration in health and function.
"These include activities such as dressing, bathing, food preparation, and
cooking. The patient/client may require adaptive equipment and/or assistive
technology in the home environment. This may include training the
patient/client and/or caregiver in the use of the equipment."  
  
 **Community/Work Reintegration**  
  
Services that are related **solely** to specific employment opportunities,
work skills, or work settings are not reasonable and necessary for the
diagnosis and treatment of an illness or injury and are excluded from coverage
by 1862(a)(1)(A) of the Social Security Act.  
  
"Community/work reintegration training describes interventions intended to
facilitate the patient's/client's ability to perform at work and in the
community at large. Training could include accessing transportation systems
and businesses, analysis of job site modification and work task analysis."  
  
This training may be medically necessary when performed in conjunction with a
patient's individual treatment plan aimed at improving or restoring specific
community functions which were impaired by an identified illness or injury and
when realistically expected outcomes are specified in the plan. This includes
training in the use of assistive technology to assist with mobility, seating
systems, and environmental control systems for use in the community. Services
must be necessary for medical treatment of an illness or injury, rather than
related solely to specific leisure or employment opportunities, work skills or
work settings.  
  
 **Work Hardening/Conditioning**

"Work hardening and work conditioning are different interventions. Work
hardening is an interdisciplinary program that is focused on tasks required
for a specific job and uses real or simulated work activities to restore
physical, behavioral, and vocational functions. Work hardening addresses
productivity, safety, physical tolerances, and worker behavior. In contrast,
work conditioning describes a work-related, intensive treatment program
designed to restore strength, flexibility, and function so that the
patient/client can return to work." These interventions are not covered.  
  
 **Wheelchair Management Training**  
  
Wheelchair management "includes assessing if the patient/client needs a
wheelchair, determining what kind of wheelchair is appropriate, including its
size and components, measuring the patient/client to ensure proper fit, and
fitting the patient/client into the chair once it is received. This includes
the time associated with training the patient/client and/or caregiver in
transfers in and out of the chair as well as propulsion on all surfaces. It is
important for the therapist to provide instructions for safety so as not to
risk skin breakdown or a fall."  
  
1\. This service trains the patient in functional activities that promote
optimal safety, mobility and transfers. Patients who use wheelchairs for
mobility may occasionally need skilled input on positioning to avoid pressure
points, contractures, and other medical complications.  
  
2\. This procedure is reasonable and necessary only when it requires the
skills of a physical therapist and is designed to address specific needs of
the patient and must be part of an active written POC directed at a specific
goal.  
  
3\. The patient and/or caregiver must have the capacity to learn from
instructions.  
  
4\. Typically, 3 to 4 sessions should be sufficient to teach the patient
and/or caregiver these skills.  
  
5\. Documentation should relate training to expected functional goals when
providing wheelchair propulsion training.

**Physical Performance Test or Measurement**  
  
This testing may be reasonable and necessary for patients with neurological or
musculoskeletal conditions when such tests are needed to formulate or evaluate
a specific written plan of treatment, or to determine a patient's functional
capacity.  
  
 **Assistive Technology Assessment**  
  
This assessment requires professional skill to gather data by observation and
patient inquiry and may include limited objective testing and measurement to
make clinical judgments regarding the patient's condition(s). Assessment
determines, e.g., changes in the patient's status since the last visit and
whether the planned procedure or service should be modified. Based on these
assessment data, the professional may make judgment about progress toward
goals and/or determine that a more complete evaluation or re-evaluation is
indicated.  
  
 **Canalith Repositioning Procedure(s) (e.g., Epley maneuver, Semont
maneuver)**  
  
Canalith repositioning procedure describes a series of movements of the
patient's body and head used for the treatment of benign paroxysmal positional
vertigo (BPPV). The procedure is used to move displaced calcium crystal debris
from the semicircular canals.