**Abstract**  
This Local Coverage Determination (LCD) describes the coverage limits of
outpatient physical and occupational therapy services under Medicare Part B,
billed to either the Medicare Part A MAC or Part B MAC when services are
provided under a therapy plan of care. These limits include specific
conditions under which certain physical and occupational therapy services may
be considered covered by Medicare. This LCD shall not be construed to either
expand or contract the limits of coverage imposed by the therapy cap as
established by Medicare. This LCD shall not be construed to expand coverage to
services defined as non-covered by National Coverage Determinations (NCDs).  
  
**Definitions**  
CLINICIAN refers to a physician, nonphysician practitioner (physician
assistant, clinical nurse specialist and nurse practitioner) or a therapist
(but not to an assistant, aide or any other personnel) providing a service
within their scope of practice and consistent with state and local law.
_Clinicians make clinical judgments and are responsible for all services they
are permitted to supervise. Services that require the skills of a therapist
may be appropriately furnished by clinicians, that is, by or under the
supervision of qualified physicians/NPPs when their scope of practice, state
and local laws allow it and their personal professional training is sufficient
to provide to the beneficiary skills equivalent to a therapist for that
service._  
  
QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist,
physician, or nonphysician practitioner (NPP) who is licensed or certified by
the state to perform therapy services. _Qualified professionals may also
include physical therapist assistants (PTA) and occupational therapy
assistants (OTA) when working under the supervision of a qualified therapist,
within the scope of practice allowed by state law._  
  
QUALIFIED AUXILIARY PERSONNEL _means staff (auxiliary personnel) who have been
educated and trained as therapists and qualify to furnish therapy services
only under direct supervision incident to a physician or NPP. Qualified
personnel may or may not be licensed as therapists but meet all of the
requirements for therapists with the exception of licensure._  
  
THERAPIST refers to physical therapists and occupational therapists qualified
according to Medicare policy.  
  
SKILLS OF A THERAPIST _are defined by the scope of practice for therapists in
the state._ For clinicians who are not therapists (e.g., physicians and NPPs),
personal professional training should be sufficient to provide to the
beneficiary skills equivalent to a therapist (OT or PT) for that service.
Skills of a therapist also include therapists supervising assistants.  
  
PROVIDER refers to a facility or agency such as a rehabilitation agency,
hospital, critical access hospitals (CAH), skilled nursing facilities (SNF),
comprehensive outpatient rehabilitation facilities (CORF), home health
agencies, or outpatient rehabilitation facilities (ORF).  
  
SUPPLIERS _of therapy services include individual practitioners such as
physicians, NPPs, physical therapists and occupational therapists who have
Medicare provider numbers._  
  
Maintenance Program (MP) means a program established by a therapist that
consists of activities and/or mechanisms that will assist a beneficiary in
maximizing or maintaining the progress he or she has made during therapy or to
prevent or slow further deterioration due to a disease or illness.  
  
 **Medical Necessity**  
 _Section 1862(a)(1)(A) of the SSA states: "No Medicare payment shall be made
for expenses incurred for items or services which . . . are not reasonable and
necessary for the diagnosis or treatment of illness or injury or to improve
the functioning of a malformed body member."_  
  
 _Services which do not meet the requirements for covered therapy services in
Medicare manuals are not payable using codes and descriptions as therapy
services. For Example, services related to activities for the general good and
welfare of patients, such as general exercises to promote overall fitness and
flexibility, and activities to provide diversion or general motivation, do not
constitute (covered) therapy services for Medicare purposes. Services related
to recreational activities such as golf, tennis, running, etc., are also not
covered as therapy services._  
  
To be considered reasonable and necessary, the services must meet Medicare
guidelines. The guidelines for coverage of outpatient therapies have basic
requirements in common.  
  
In the case of rehabilitative therapy, the patient's condition has the
potential to improve or is improving in response to therapy, maximum
improvement is yet to be attained; and there is an expectation that the
anticipated improvement is attainable in a reasonable and generally
predictable period of time.

  * Improvement is evidenced by successive objective measurements whenever possible. If an individual's expected rehabilitation potential is insignificant in relation to the extent and duration of therapy services required to achieve such potential, rehabilitative therapy is not reasonable and necessary.
  * Therapy is not required to effect improvement or restoration of function where a patient suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activates (CMS Publication 100.02-, Medicare benefit Policy Manual, chapter 15, section 220.2(C)). For example, therapy may not be covered for a fully functional patient who developed temporary weakness from a brief period of bed rest following abdominal surgery. It is reasonably expected that as discomfort reduces and the patient gradually resumes daily activities, function will return without skilled therapy intervention.

  
_In the case of maintenance therapy, treatment by the therapist is necessary
to maintain, prevent or slow further deterioration of the patient 's
functional status and the services cannot be safely carried out by the
beneficiary him or herself, a family member, another caregiver, or unskilled
personnel._  
A therapy plan of care is developed either by the physician/NPP, or by the
physical therapist who will provide the physical therapy services, or the
occupational therapist who will provide the occupational therapy services,
(only a physician may develop the plan of care in a CORF). The plan must be
certified by a physician/NPP.  
If the goal of the plan of care is to improve functioning, the documentation
must establish that the patient needs the unique skills of a therapist to
improve functioning.  
If the goal of the plan of care is to maintain, prevent, or slow further
deterioration of functional status function or prevent deterioration, the
documentation must establish that the patient needs the unique skills of a
therapist to maintain, prevent, or slow further deterioration of functional
status  
  
All services provided are to be specific and effective treatments for the
patient's condition according to accepted standards of medical practice; and
the amount, frequency, and duration of the services must be reasonable.  
  
The services that are provided must meet the description of skilled therapy
below.  
  
 **Skilled Therapy**  
 _A service is not considered a skilled therapy service merely because it is
furnished by a therapist or by a therapist/therapy assistant under the direct
or general supervision, as applicable, of a therapist. If a service can be
self-administered or safely and effectively furnished by an unskilled person,
without the direct or general supervision, as applicable, of a therapist, the
service cannot be regarded as a skilled therapy service even though a
therapist actually furnishes the service. Similarly, the unavailability of a
competent person to provide a non-skilled service, notwithstanding the
importance of the service to the patient, does not make it a skilled service
when a therapist furnishes the service.  
Skilled therapy services may be necessary to improve a patient's current
condition, to maintain the patient's current condition, or to prevent or slow
further deterioration of the patient's condition._  
Services that do not require the professional skills of a therapist to perform
or supervise are not medically necessary. The skills of a therapist may also
be furnished by an appropriately trained and experienced physician or NPP, or
by an assistant (PTA, OTA) appropriately supervised by a therapist. Therefore,
if a patient's therapy can proceed safely and effectively through a home
exercise program, self management program, restorative nursing program or
caregiver assisted program, payment cannot be made for therapy services.  
Consider the following points when determining if a service is skilled.

    * _Rehabilitative therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in each state) are necessary to safely and effectively furnish a recognized therapy service, whose goal is improvement of an impairment or functional limitation._  

      * The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can only be safely and effectively performed by a qualified clinician, or therapists supervising assistants.



    * Maintenance therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in each state) are necessary to safely and effectively furnish a recognized therapy service, whose goal is to maintain functional status or prevent or slow further deterioration in functional status.  

        * If the specialized skill, knowledge, and judgement of a qualified therapist are required to establish or design a maintenance program to maintain the patient's current condition or to prevent or slow further deterioration, the establishment or design of a maintenance program by a qualified therapist is covered.
        * If skilled therapy services by a qualified therapist are needed to instruct the patient or appropriate caregiver regarding the maintenance program, such instruction is covered.
        * If skilled therapy services are needed for periodic reevaluations or reassessments of the maintenance program, such periodic reevaluations or reassessments are covered.
        * Such skilled care is necessary for the performance of a safe and effective maintenance program only when;  

          * The therapy procedures required to maintain the patient's current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to furnish the therapy procedure or
          * The particular patient's special medical complications require the skills of a qualified therapist to furnish a therapy service required to maintain the patient's current function or to prevent or slow further deterioration, even if the skills of a therapist are not ordinarily needed to perform such therapy procedure.
  

      * Once a maintenance program is established, coverage of therapy services to carry out a maintenance program turns on the beneficiary's need for skilled care. A maintenance program can generally be performed by the beneficiary alone or with the assistance of a family member, caregiver, or unskilled personnel. In such situations, coverage is not provided. However, skilled therapy services are covered when an individualized assessment of the patient's clinical condition demonstrates that the specialized judgement, knowledge, and skills of a qualified therapist are necessary for the performance of safe and effective services in a maintenance program.



    * _While a beneficiary 's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a beneficiary's diagnosis or prognosis should never be the sole factor in deciding that a service is or is not skilled. The key issue is whether the skills of a qualified therapist are needed to treat the illness or injury, or whether the service(s) can be carried out by non-skilled personnel._
    * If at any point in the treatment it is determined that the treatment becomes repetitive and does not require the unique skills of a therapist, the services are non-covered.
    * There may be circumstances where the patient, with or without the assistance of an aide or other caregiver, does activities planned by a clinician. Although these activities may be supportive to the patient's treatment, if they can be done by the patient, aides or other caregivers without the active participation of qualified professional/auxiliary personnel, they are considered unskilled.
    * An individualized plan of exercise and activity for patients and their caregiver(s) may be developed by clinicians to maintain and enhance a patient's progress during the course of skilled therapy, as well as after discharge from therapy services. Such programs are an integral part of therapy from the start of care and should be expected and modified as the patient progresses.  

      * If a patient's limited ability to comprehend instructions, follow directions, or remember skills that are necessary to achieve an increase in function, is so severe as to make functional improvement very unlikely, rehabilitative therapy is not required, and therefore, is not covered. However, limited services in these circumstances may be covered with supportive documentation, if the skills of a therapist are required to establish and teach a caregiver a safety or maintenance program.



      * This does not apply to the limited situations where rehabilitative therapy is reasonable and achieving meaningful goals is appropriate, even when a patient does not have the ability to comprehend instructions, follow directions or remember skills. Examples include sitting and standing balance activities that help a patient recover the ability to sit upright in a seat or wheel-chair, or safely transfer from the wheelchair to a toilet.
      * This also does not apply to those patients who have the potential to recover abilities to remember or follow directions, and treatment may be aimed at rehabilitating these abilities, such as following a traumatic brain injury.



  * The use of therapy equipment such as therapeutic pools or gym machines alone does not necessarily make the treatment skilled.
  * Medicare does not cover packaged or predetermined therapy services or programs, such as Back Schools or pre-operative joint classes with preset educational activities and exercises for all participants involved. Services must be individualized, medically necessary and require the unique skills of a therapist. (Packaged or predetermined therapy services do not apply to post-surgical protocols that provide ranges and guidance.)

  
  
  
**Personnel Authorized to Provide Outpatient Therapy Services**  
Medicare billable therapy services may be provided by any of the following
within their scope of practice and consistent with state and local law:

  * Physician;
  * Non-physician practitioner (NPP) (physician assistants, nurse practitioners, clinical nurse specialists);
  * Qualified physical and occupational therapists, speech language pathologists, and assistants working under the supervision of a qualified therapist;
  * Qualified personnel, with or without a license to practice therapy, who have been educated and trained as therapists and qualify to furnish therapy services only under direct supervision incident to a physician or NPP.

  
  
The new personnel qualifications for physical therapists, physical therapist
assistants, occupational therapists and occupational therapy assistants were
discussed in the 2008 Physician Fee Schedule. See the Federal Register of
November 27, 2007 for the full text. See also the correction notice for this
rule, published in the Federal Register on January 15, 2008.  
  
 **Personnel NOT Authorized to Provide Outpatient Therapy Services**  
Students*, aides, athletic trainers, exercise physiologists, massage
therapists, recreation therapists, kinesiotherapists, low vision specialists,
lymphedema specialists, Pilates instructors, rehabilitation technicians and
life skills trainers are not considered qualified therapy professionals and
may not bill their services under the Medicare therapy benefit, even if
performed under the supervision of a qualified therapist.  
* See Therapy Students section for further clarification regarding student participation in treatment.  
CMS established the qualifications to assure that all personnel who provide
therapy services are suitably trained in the discipline they practice.
Personnel who do not meet the applicable professional standards to be
considered qualified professional/personnel cannot furnish or be paid for
physical or occupational therapy services.  
  
 **Therapy Students**  
Qualified professionals may serve as clinical instructors for therapy students
within their scope of practice. Physical therapist assistants and occupational
therapy assistants may only serve as clinical instructors for physical
therapist assistant students and occupational therapy assistant students,
respectively, when performed under the direction and supervision of the
licensed physical or occupational therapist (in states where licensure
applies).  
Services performed by a student (therapy student or therapy assistant student)
are not reimbursed, even if provided under "line of sight" supervision of the
therapist. However, the services of a qualified professional are covered, even
when a student is participating in the care.  
To be covered when the student is participating, the qualified professional
must be present in the room and must:

  * Direct the service, making the skilled judgment and assessment, and assume responsibility for the treatment;
  * Not be engaged in treating another patient or doing other tasks at the same time (such as documentation); AND must
  * Sign all documentation appropriately. A student may also sign the documentation, but it is not necessary since the Part B payment is for the qualified professional's service, not for the student's services.

  
  
**Supervision Levels**  
Supervision levels for outpatient therapy services depend on the setting where
they are provided. Direct supervision (in the office suite) by a physician/NPP
is required for therapists and qualified auxiliary personnel when therapy
services are provided incident to the services of a physician/NPP. Also,
direct supervision by a physical therapist (for PTAs) or occupational
therapist (for OTAs) is required when assistants provide therapy services in
the private practice setting or in the office of a physician/NPP. General
supervision (the supervising therapist is available but not necessarily on the
premises) is required by a physical therapist (for PTAs) or occupational
therapist (for OTAs) when therapy services are provided in any other setting.  
  
 **Private Practice Therapy Services**  
All therapy medical necessity, certification, documentation and coding
guidelines of this LCD apply to all outpatient settings, including therapy
services provided by private practitioners. In addition, in the private
practice setting, all services not performed by the therapist must be
performed by an assistant who is an employee of the practice and must be under
direct supervision of the therapist.  
  
To qualify as a private practice, each individual must be enrolled as a
private practitioner and employed in one of the following practice types:

  * Unincorporated solo practice, partnership, or group practice;
  * Physician/NPP group or groups that are not professional corporations, if allowed by state and local law;
  * Physical or occupational therapist employed by physician/NPP group practices (PTPP, OTPP), if state and local law permits this employee relationship.

  
_Private practice also includes therapists who are practicing therapy as
employees of another supplier, of a professional corporation or other
incorporated therapy practice. Private practice does not include individuals
when they are working as employees of an institutional provider._  
 _Services should be furnished in the therapist 's or group's office or in the
patient's home. The office is defined as the location(s) where the practice is
operated during the hours that the therapist engages in the practice at that
location. If the services are furnished in a private practice office space,
that space shall be owned, leased, or rented by the practice and used for the
exclusive purpose of operating the practice._  
  
 **Therapy Provided by Physicians and Physician Employees**  
Physical and occupational therapy services may be provided by physicians, non-
physician practitioners (NPPs), or incident-to the services of physicians/NPPs
when provided by physical or occupational therapists, in the office or home.
All therapy medical necessity, certification, documentation, and coding
guidelines of this LCD apply with one exception. When therapy services are
performed incident-to a physician's/NPP's service, the therapist does not need
a license to practice therapy, unless it is required by state law. All other
physical or occupational therapist qualifications (education and training)
must be met. Therapy services must be directly supervised. _The services of
PTAs and OTAs also may not be billed incident to a physician 's/NPP's service.
However, if a PT and PTA (or an OT and OTA) are both employed in a physician's
office, the services of the PTA, when directly supervised by the PT or the
services of the OTA, when directly supervised by the OT may be billed by the
physician group as PT or OT services using the PIN/NPI of the enrolled PT (or
OT). (See Section 230.4 for private practice rules on billing services
performed in a physician's office.) If the PT or OT is not enrolled, Medicare
shall not pay for the services of a PTA or OTA billed incident to the
physician's service, because they do not meet the qualification standards in
42CFR484.4._  
  
 **Indications and Limitations of Coverage and/or Medical Necessity:**  
  
The following services are typically considered rehabilitative. This is not
intended to be an exhaustive list of therapy services and does not assure
coverage.  
  
Therapy services should be provided in a manner that meets the patient's
needs. The treatment plan should strive to provide treatment in the most
efficient and effective manner, balancing the best achievable outcome with the
appropriate resources. Because medical review decisions are made based on
documentation in the medical record, this LCD provides recommendations
intended to assist qualified professionals/auxiliary personnel in documenting
to support both the medical necessity and the skilled nature of the therapy
services provided. In addition, any numerical guidelines related to individual
codes in this section of the LCD, are based on contractor medical review
experience. These are provided to remind qualified professionals/auxiliary
personnel of the importance of justifying therapy services in the
documentation as the patient progresses through an episode of care. The
guidelines presented under the sections "Supportive Documentation
Recommendations" are not mandated, and it is not necessary to document these
recommended points for each treatment session (unless otherwise specified in
the LCD).  
Please refer to CMS publication 100-02, Medicare Benefit Policy Manual,
Chapter 15, section 220.3 for the Medicare minimal documentation requirements
for therapy services.  
  
 **PT evaluation   OT evaluation**  
The initial evaluation should document the necessity of a course of therapy
through objective findings and subjective patient/caregiver self-reporting.
Initial evaluations must be completed by the therapist or physician/NPP that
will be providing the therapy services. Initial evaluations are completed to
determine the medical necessity of initiating rehabilitative therapy or
skilled instruction in maintenance activities that the patient and/or
caregiver can perform at home.  
Initial evaluation may be warranted when there is a change in functional
ability. The evaluation should clearly describe the presenting complaint or
problem for which the patient is seeking services of the physical or
occupational therapist.  
The evaluation process assesses, for example, the severity and impact of the
current problem, the possibility of multi-site or multi-system involvement,
the presence of pre-existing systemic conditions (e.g., diseases), and the
stability of the condition. If the patient presents with multi-system
involvement and/or multiple site involvement, all pertinent areas/conditions
should be assessed at the initial evaluation (i.e., cervical pain and knee
pain; low back pain and rotator cuff irritation; cervical pain and low back
pain). Only one initial evaluation code should be used, and all presenting
complaints and problems evaluated. If over the course of an episode of
treatment, a new, unrelated diagnosis occurs, another initial evaluation may
be covered.  
  
Initial evaluations may be covered when the documentation justifies the need
for a skilled therapy evaluation, even if it is determined that the patient
does not require a skilled level of treatment.

  * _When an evaluation is the only service provided by a provider/supplier in an episode of treatment, the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP. The goal, frequency, and duration of treatment are implied in the diagnosis and one-time service. The referral/order of a physician/NPP is the certification that the evaluation is needed and the patient is under the care of a physician. Therefore, when evaluation is the only service, a referral/order and evaluation are the only required documentation. If the patient presented for evaluation without a referral or order and does not require treatment, a physician referral/order or certification of the evaluation is required for payment of the evaluation. A referral/order dated after the evaluation shall be interpreted as certification of the plan to evaluate the patient._

  
Screening may be more appropriate than evaluation in some circumstances. For
example, a patient develops an acute lateral epicondylitis from painting. The
patient seeks physician attention who subsequently recommends that the patient
see an occupational therapist. By the time the patient sees the OT, she
presents without any pain and has resumed all normal functional activities.
Completing a screening interview of this patient should lead the therapist to
determine that an OT evaluation and treatment would not be medically
necessary.

  * A screening is the gathering of information to determine the need for further evaluation by the clinician. The screening process may include a review of the patient's medical record, a patient interview and observation of the patient.
  * Routine screening is not a billable service. Although some regulations and state practice acts require screening evaluations at specific intervals (such as at admission to a nursing home, or quarterly during the patient's stay), for Medicare payment, evaluations must meet Medicare coverage guidelines.

  
Initial evaluations from other therapy disciplines performed on the same
beneficiary may also be covered, provided the evaluation and plan of care are
not duplicative.  
For initial evaluations, physical therapists and occupational therapists
should use the appropriate physical therapy and/or occupational therapy
evaluation code. Physicians and other qualified non-physician providers should
use the evaluation and management codes for evaluations.  
  
Consider the following points when billing for an evaluation.

  * These evaluation codes are untimed, billable as one unit.
  * Do not bill for a therapy initial evaluation for each therapy discipline on more than one date of service. If an evaluation spans more than one day, the evaluation should only be billed as one unit for the entire evaluation service (typically billed on the day that the evaluation is completed). Do not count as therapy "treatment" the additional minutes needed to complete the evaluation during the subsequent session(s).
  * Do not bill test and measurement, range of motion (ROM) or manual muscle testing (MMT) codes on the same day as the initial evaluation. The procedures performed are included in the initial evaluation codes and are not allowed by the Correct Coding Initiative (CCI) edits.
  * Do not bill therapy screenings utilizing the evaluation codes. Screenings are not billable services.
  * Evaluations for deconditioning after hospitalization where it is anticipated that prior functional abilities would spontaneously return through patient, caregiver and/or nursing activities are not considered medically necessary and are not covered.
  * Pre-operative evaluations performed routinely to ascertain the patient's post- surgical needs and/or to explain the services that will be provided post-operatively are non-covered. The patient's post-op experience and functional limitations are unknown prior to the surgery and will at that time require a new evaluation of the situation when medically necessary.
  * If treatment is given on the same day as the initial evaluation, the treatment is billed using the appropriate CPT codes. The documentation must clearly describe the treatment that was provided in addition to the evaluation.

  
**Supportive Documentation Recommendations for physical therapy and
occupational therapy evaluation codes**  
Refer to the Documentation Requirements Section of this LCD for further
information.  
  
 **PT reevaluation   OT reevaluation**  
 _The reevaluation 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. Reevaluation provides additional
objective information not included in other documentation, such as treatment
or progress notes._  
  
Reevaluations are distinct from therapy assessments. Assessments are
considered a routine aspect of intervention and are not billed separately from
the intervention. For example, a patient is being seen in physical or
occupational therapy for shoulder pain and limited shoulder functional range
of motion due to capsular tightness. Prior to performing shoulder joint
mobilizations, the therapist assesses the patient's ROM and pain level/pattern
to determine the effect of prior treatment and, if further mobilization is
warranted, to determine the appropriate mobilizations. After the mobilizations
are completed, the ROM is assessed again to determine the effects of the
treatment just performed. The time required to assess the patient before and
after the intervention is added to the minutes of the treatment intervention.
_Continuous assessment of the patient 's progress is a component of the
ongoing therapy services, and is not payable as a reevaluation._  
  
Consider the following points when billing for a reevaluation.

  * _Indications for a reevaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care._
  * When reevaluations are done for a significant change in condition, documentation must show a significant improvement, decline or change in the patient's diagnosis, condition or functional status that was not anticipated in the current plan of care. When a patient exhibits a demonstrable change in functional ability, a reevaluation may be necessary to revise long term goals and interventions. The plan of care may need to be revised and recertified if significant changes are made, such as a change in the long-term goals.
  * If a patient is hospitalized during the therapy interval, a reevaluation may be medically necessary if there has been a significant change in the patient's condition which has caused a change in function, long term goals, and/or treatment plan.
  * Reevaluations may be appropriate at a planned discharge when documentations supports the medical necessity for the reevaluation service.
  * Therapy reevaluations should contain all the applicable components of an initial evaluation and must be completed by a clinician. (See the Reevaluation section of Documentation Requirements for information regarding therapy assistant participation in the reevaluation process.)
  * A reevaluation is not a routine, recurring service. Do not bill for routine reevaluations, including those done for the purpose of completing an updated plan of care, a recertification report, a progress report, or a physician progress report. _Although some state regulations and practice acts require reevaluations at specific intervals, for Medicare payment, reevaluations must meet Medicare coverage guidelines._
  * These reevaluation codes are untimed, billable as one unit.
  * Do not bill for reevaluations as unlisted codes or test and measurement, ROM, MMT codes.

  
**Supportive Documentation Recommendations for reevaluations**  
Refer to the Documentation Requirements Section of this LCD for further
information.  
  
 **MODALITIES**  
  
 **General Modality Guidelines**  
  
General modalities such as traction, paraffin baths, whirlpool, vasopneumatic
devices, infrared, ultraviolet, and diathermy require supervision by the
qualified professional/auxiliary personnel of the patient during the
intervention.  
General modalities such as electrical stimulation, contrast baths, ultrasound,
iontophoresis, hubbard tank, and any time a modality does not have a specific
code that needs to use unlisted modality code require direct (one-on-one)
contact with the patient by the provider (constant attendance). Coverage for
these codes indicates the provider is performing the modality and cannot be
performing another procedure at the same time. Only the actual time of the
provider's direct contact with the patient, providing services requiring the
skills of a therapist, is covered for these codes.  
Modalities chosen to treat the patient's symptoms/conditions should be
selected based on the most effective and efficient means of achieving the
patient's functional goals. Seldom should a patient require more than one (1)
or two (2) modalities to the same body part during the therapy session. Use of
more than two (2) modalities on each visit date is unusual and should be
carefully justified in the documentation.  
The use of modalities as stand-alone treatments is rarely therapeutic, and
usually not required or indicated as the sole treatment approach to a
patient's condition. The use of exercise and activities has proven to be an
essential part of a therapeutic program.  
Therefore, a treatment plan should not consist solely of modalities, but
should also include therapeutic procedures. (There are exceptions, including
wound care or when patient care is focused on modalities because the acute
patient is unable to endure therapeutic procedures.) Use of only passive
modalities that exceeds 4 visits should be very well supported in the
documentation.  
  
Multiple heating modalities should not be used on the same day. Exceptions are
rare and usually involve musculoskeletal pathology/injuries in which both
superficial and deep structures are impaired. Documentation must support the
use of multiple modalities as contributing to the patient's progress and
restoration of function. For example, it would not be medically necessary to
perform both thermal ultrasound and thermal diathermy on the same area, in the
same visit, as both are considered deep heat modalities.  
When the symptoms that required the use of certain modalities begin to subside
and function improves, the medical record should reflect the discontinuation
of those modalities, so as to determine the patient's ability to self-manage
any residual symptoms. As the patient improves, the medical record should
reflect a progression of the other procedures of the treatment program
(therapeutic exercise, therapeutic activities, etc.). In all cases, the
patient and/or caregiver should be taught aspects of self-management of
his/her condition from the start of therapy.  
  
Based on the CPT descriptors, these modalities apply to one or more areas
treated (e.g., paraffin bath used for the left and right hand is billed as one
unit).  
  
 **Hot or cold packs therapy**  
Hot or cold packs (including ice massage) applied in the absence of associated
procedures or modalities, or used alone to reduce discomfort are considered
not to require the unique skills of a therapist.  
Hot or cold pack therapy may be bundled with any therapy code. Regardless of
whether code this is billed alone or in conjunction with another therapy code,
this code is never paid separately. If billed alone, this code will be denied.  
 **Supportive Documentation Recommendations for hot or cold pack therapy**

  * The area(s) treated
  * The type of hot or cold application

  
  
**Mechanical traction therapy**  
Traction is generally limited to the cervical or lumbar spine with the
expectation of relieving pain in or originating from those areas.  
  
Specific indications for the use of mechanical traction include cervical
and/or lumbar radiculopathy and back disorders such as disc herniation,
lumbago, and sciatica.  
This modality is typically used in conjunction with therapeutic procedures,
not as an isolated treatment.  
Documentation should support the medical necessity of continued traction
treatment in the clinic for greater than 12 visits. For cervical conditions,
treatment beyond one month can usually be accomplished by self-administered
mechanical traction in the home. The time devoted to patient education related
to the use of home traction should be billed under 97012.  
Only 1 unit of mechanical traction therapy is generally covered per date of
service.  
Equipment and tables utilizing roller systems are not considered true
mechanical traction. Services using this type of equipment are non-covered.  
  
 _Non-Surgical Spinal Decompression_ Non-surgical spinal decompression _is
performed for symptomatic relief of pain associated with lumbar disk problems.
The treatment combines pelvic and/or cervical traction connected to a special
table that permits the traction application. There is insufficient scientific
data to support the benefits of this technique. Therefore, non-surgical spinal
decompression is not covered by Medicare (CMS Publication 100-03, Medicare
National Coverage Determinations (NCD) Manual: Section 160.16)._ Examples of
this type of non-covered procedure include, but are not limited to, VAX-DTM,
DRX-3000, DRX9000, Decompression Reduction Stabilization (DRS) System, IDD,
MedX., Spina System, Accua-Spina System, SpineMED Decompression Table, Lordex
Traction Unit, Triton DTS, and Z-Grav. If billed for purpose of receiving a
denial, these services should be billed using an unlisted modality CPT code.  
  
 **Supportive Documentation Recommendations for mechanical traction therapy**

  * Type of traction and part of the body to which it is applied, etiology of symptoms requiring treatment.

  
**Electrical stimulation (unattended)**  
The AMA CPT for electrical stimulation is not a Medicare recognized code. See
HCPCS code for electrical stimulation (unattended).

  
**Vasopneumatic device therapy**  
The use of vasopneumatic devices may be considered reasonable and necessary
for the application of pressure to an extremity for the purpose of reducing
edema or lymphedema.  
  
  
  
Specific indications for the use of vasopneumatic devices include reduction of
edema after acute injury or lymphedema of an extremity. Education on the use
of a lymphedema pump for home use is covered when medically necessary and can
typically be completed in three (3) or fewer visits once the patient has
demonstrated measurable benefit in the clinic environment.  
Note: Further treatment of lymphedema by a vasopneumatic device rendered by a
clinician after the educational visits is generally not reasonable and
necessary unless the patient presents with a condition or status requiring the
skills and knowledge of a physical or occupational therapist.  
The use of vasopneumatic devices is generally not covered as a temporary
treatment while awaiting receipt of ordered compression stockings.  
See NCD 280.6 in CMS Publication 100-03, _Medicare National Coverage
Determinations (_ NCD) Manual for further coverage and use information on
Pneumatic Compression Devices.  
  
 **Supportive Documentation Recommendations for vasopneumatic device therapy**

  * Area of the body being treated, location of edema
  * Objective edema measurements (1+, 2+ pitting, girth, etc), comparison with uninvolved side
  * Effects of edema on function Type of device used

  
  
**Paraffin bath therapy**  
Paraffin bath treatments typically do not require the unique skills of a
therapist. However, the skills, knowledge and judgment of a therapist might be
required in the provision of such treatment or baths in a complicated case.
Only in cases with complicated conditions will paraffin be covered, and then
coverage is generally limited to educating the patient/caregiver in home use.
Paraffin is contraindicated for open wounds or areas with documented
desensitization.  
Once a trial of monitored paraffin treatment has been done in the clinic over
1-2 visits and the patient has had a favorable response, the patient can
usually be taught to use a paraffin unit in 1-2 visits. Consequently, it is
inappropriate for a patient to continue paraffin treatment in the clinic
setting.

  * Only 1 unit of paraffin bath therapy is generally covered per date of service.
  * Documentation needs to support more than 2 visits to educate patient and/or caregiver in home use once effectiveness has been determined.

  
  
**Supportive Documentation Recommendations for paraffin bath therapy**

  * Rationale for requiring the unique skills of a therapist to apply and train the patient/caregiver, including the complicating factors
  * Area of body treated

  
  
**Whirlpool therapy**  
Whirlpool bath treatments typically do not require the unique skills of a
therapist. However, therapist supervision of the whirlpool modality may be
medically necessary for the following indications:

  * a condition complicated by a circulatory deficiency or areas of desensitization;
  * an open wound which is draining, has a foul odor, or necrotic tissue;
  * exfoliative skin impairments.

  
  
If greater than 8 visits are needed for whirlpools that require the skills of
a therapist, the documentation should support the medical necessity of the
continued treatment.  
Only 1 unit of whirlpool therapy should be billed per date of service.  
Dry hydrotherapy massage (also known as aquamassage, hydromassage, or water
massage) is considered investigational and is non-covered.  
Whirlpool should not be separately billed when provided on the same date of
service as debridement for the same body part.  
 __

**_Fluidotherapy_**  
Fluidotherapy is a superficial dry heat modality consisting of a whirlpool of
finely divided solid particles suspended in a heated air stream, the mixture
having the properties of a liquid. _Use of fluidized therapy dry heat is
covered as an acceptable alternative to other heat therapy modalities in the
treatment of acute or sub-acute traumatic or non- traumatic musculoskeletal
disorders of the extremities._ (CMS Publication 100-03, Medicare National
Coverage Determinations (NCD) Manual, Chapter 1, Section 150.8)  
  
 **Supportive Documentation Recommendations for fluidotherapy**

  * Rationale for requiring the unique skills of a therapist to apply, including the complicating factors
  * Area(s) being treated

  
  
  
**Diathermy eg microwave**  
The objective of these treatments is to cause vasodilation and relieve pain
from muscle spasm. Because heating is accomplished without physical contact
between the modality and the skin, it can be used even if skin is abraded, as
long as there is no significant edema.  
Diathermy achieves a greater rise in deep tissue temperature than microwave.
As diathermy is considered a deep heat treatment, careful consideration should
be given to the size, location and depth of the tissue the diathermy is
intended to heat. For example, it may not be appropriate to perform diathermy
treatment to the wrist or hand as most intended tissues would be considered
superficial and the area is relatively small.  
Diathermy may be indicated when a large area of deep tissues requires heat. It
would not be reasonable and necessary to perform both thermal ultrasound and
diathermy to the same region of the body in the same visit as both are
considered deep heat modalities.  
Pulsed wave diathermy is covered for the same conditions and to the same
extent as standard diathermy. (CMS Publication 100-03, _Medicare National
Coverage Determinations_ (NCD) Manual, Section 150.5)  
  
Both standard and pulsed wave diathermy are contraindicated in the following
settings:

  * Malignancy;
  * Sensory loss; Tuberculosis;
  * Metallic implants or foreign bodies;
  * Pregnancy;
  * Application over moist dressings; Ischemic areas or arteriosclerosis;
  * Thromboangiitis obliterans;
  * Phlebitis;
  * Cardiac pacemakers or other such implanted devices (e.g. pain pumps);
  * Contact lenses or other ocular use;
  * Metal-containing intrauterine contraceptive devices;
  * Metal in contact with skin (eg, watches, belt buckles, jewelry);
  * Use over epiphyseal areas of developing bones;
  * Active menses;

  
  
  
In addition, extreme care must be used with pediatric or geriatric patients.  
  
  
  
Diathermy is not considered reasonable and necessary for the treatment of
asthma, bronchitis, or any other pulmonary condition. (CMS Publication 100-03,
_Medicare National Coverage Determinations_ (NCD) Manual, Section 240.3)
Microwave is not a covered service.  
  
Only 1 unit of diathermy is covered per date of service. If no objective
and/or subjective improvement are noted after 6 treatments, a change in
treatment plan (alternative strategies) should be implemented, or
documentation should include the therapist's rationale for continued
diathermy. Documentation must clearly support the need for diathermy more than
12 visits.  
 **Supportive Documentation Recommendations for Diathermy**

  * Area(s) being treated
  * Objective clinical findings/measurements to support the need for a deep heat treatment
  * Subjective findings to include pain ratings, pain location, activities which increase or decrease pain, effect on function, etc.

  
  
**Infrared therapy-including Anodyne**  
  
 _Not covered_ : _The Centers for Medicare & Medicaid Services has determined
that there is sufficient evidence to conclude the use of infrared therapy
devices and any related accessories is not reasonable and necessary. The use
of infrared and/or near-infrared light and/or heat, including monochromatic
infrared energy, is non-covered for the treatment, including the symptoms such
as pain arising from these conditions, of diabetic and/or non-diabetic
peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or
subcutaneous tissues. See CMS Publication 100-03 Medicare National Coverage
Determinations _(NCD) Manual, section 270.6 and Publication 100-04, Medicare
Claims Processing Manual, Chapter 5, section 20.4.  
  
 **Ultraviolet therapy**  
Treatment of this type is generally used for patients requiring the
application of a drying heat. For example, this treatment would be considered
reasonable and necessary for the treatment of severe psoriasis where there is
limited range of motion.  
  
Only 1 unit of ultraviolet therapy is covered per date of service.  
  
 **Supportive Documentation Recommendations for ultraviolet therapy**

  * Area(s) being treated
  * Objective clinical findings/measurements to support the need for ultraviolet
  * Minimal erythema dosage

  
**Electrical stimulation**  
  
Most non-wound care electrical stimulation treatment provided in therapy is
often provided in a supervised manner (after skilled application by the
qualified professional/auxiliary personnel) without constant, direct contact
required throughout the treatment.  
Manual electrical stimulation is a constant attendance electrical stimulation
modality that requires direct (one- on-one) manual patient contact by the
qualified professional/auxiliary personnel. Because the use of a constant,
direct contact electrical stimulation modality is less frequent, documentation
should clearly describe the type of electrical stimulation provided.  
Types of electrical stimulation that may require constant attendance when
continuous presence by the qualified professional/auxiliary personnel is
required include the following examples.

    * Direct motor point stimulation delivered via a probe
    * Instructing a patient in the use of a home TENS unit  

      * Once a trial of TENS has been done in the clinic over 1-2 visits and the patient has had a favorable response, the patient can usually be taught to use a TENS unit for pain control in 1-2 visits. Consequently, it is inappropriate for a patient to continue treatment for pain with a TENS unit in the clinic setting.
      * Note that the application of surface (transcutaneous) neurostimulator and is an operative/postoperative code. Use of this code would seldom fall under a therapy plan of treatment.



    * Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES) while performing a therapeutic exercise or functional activity may be billed. Do not bill for therapeutic procedure for the same time period.  

      * _Use for Walking in Patients with Spinal Cord Injury (SCI)_ the type of NMES that is used to enhance the ability to walk of SCI patients is commonly referred to as functional electrical stimulation (FES). See the section on gait training for information on coverage for this use of NMES. (CMS Publication 100-03, _Medicare National Coverage Determinations_ (NCD) Manual, section 160.12)



  * Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound. Do not bill for both ultrasound and electrical stimulation for the same time period.
  * If providing an electrical stimulation modality that is typically considered supervised to a patient requiring constant attendance for safety reasons due to cognitive deficits, do not bill as manual electrical stimulation. This type of monitoring may be done by non-skilled personnel.

  
  
_Non-Implantable Pelvic Floor Electrical Stimulation_ (CMS Publication 100-03,
_Medicare National Coverage Determinations_ (NCD) Manual, section 230.8.)

  * Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature.

  
Stimulation delivered by vaginal or anal probes connected to an external pulse
generator may be billed as manual electrical stimulation. Stimulation
delivered via electrodes should be billed as unattended electrical
stimulation.

  * _The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.  
_

  * _Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.  
_

  * _A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.  
_

  * _The patient's medical record must indicate that the patient receiving a non- implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training._

  
Utilization of electrical stimulation may be necessary during the initial
phase of treatment, but there must be an improvement in function. These
modalities should be utilized with appropriate therapeutic procedures to
effect continued improvement. Note: Coverage for this indication is limited to
those patients where the nerve supply to the muscle is intact, including
brain, spinal cord, and peripheral nerves and other non- neurological reasons
for disuse are causing the atrophy (e.g., post-casting or splinting of a limb,
and contracture due to soft tissue scarring).  
Documentation must clearly support the medical necessity of electrical
stimulation more than 12 visits as adjunctive therapy or for muscle
retraining.  
  
Some patients can be trained in the use of a home muscle stimulator for
retraining weak muscles. Only 1-2 visits should be necessary to complete the
training. Once training is completed, this procedure should not be billed as a
treatment modality in the clinic.  
  
 _Non-covered Indications_

  * Electrical Stimulation used in the treatment of facial nerve paralysis, commonly known as Bell's palsy (CMS Manual 100-03, _Medicare National Coverage Determinations_ (NCD) Manual, section 160.15)
  * Electrical Stimulation used to treat motor function disorders such as multiple sclerosis (CMS Manual 100-03, _Medicare National Coverage Determinations_ (NCD) Manual, section 160.2)
  * Electrical Stimulation for the treatment of strokes when it is determined there is no potential for restoration of function
  * Electrical Stimulation when it is the only intervention utilized purely for strengthening of a muscle with at least Fair graded strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activities.

  
**Supportive Documentation Recommendations for electrical stimualtion**

  * Type of electrical stimulation used (do not limit the description to "manual" or "attended")
  * Area(s) being treated
  * If used for muscle weakness, objective rating of strength and functional deficits
  * If used for pain include pain rating, location of pain, effect of pain on function

  
**Electric current therapy**  
Iontophoresis is the introduction into the tissues, by means of an electric
current, of the ions of a chosen medication. This modality is used to reduce
pain and edema caused by a local inflammatory process in soft tissue, e.g.,
tendonitis, bursitis.  
The evidence from published, peer-reviewed literature is insufficient to
conclude that the iontophoretic delivery of non-steroidal anti-inflammatory
drugs (NSAIDs) or corticosteroids is superior to placebo when used for the
treatment of musculoskeletal disorders. Therefore, iontophoresis will not be
covered for these indications.  
Iontophoresis will be allowed for treatment of intractable, disabling primary
focal hyperhidrosis that has not been responsive to recognized standard
therapy. Good hygiene measures, extra-strength antiperspirants (for axillary
hyperhidrosis), and topical aluminum chloride should initially be tried.  
  
 **Contrast baths therapy**  
Contrast baths are a form of therapeutic heat and cold applied to distal
extremities in an alternating pattern. The effectiveness of contrast baths is
thought to be due to reflex hyperemia produced by the alternating exposure to
heat and cold.  
Hot and cold baths ordinarily do not require the skills of a therapist.
However, the skills, knowledge and judgment of a therapist might be required
in the provision of such treatments in a particular case, e.g., where the
patient's condition is complicated by circulatory deficiency, areas of
desensitization, open wounds, fracture or other complication.  
Documentation must indicate the presence of these complicating factors for
reimbursement of this code. If there are no complicating factors requiring the
skills of a therapist, this modality is non-covered.  
Contrast bath therapy is not covered when the services provided are hot and
cold packs.  
This modality should be used in conjunction with therapeutic procedures, not
as an isolated treatment.  
No more than 2 visits will generally be covered to educate the patient and/or
caregiver in home use, and to evaluate effectiveness. Documentation must
support the medical necessity of continued use of this modality for greater
than 2 visits.  
This is a constant attendance code requiring direct, one-on-one patient
contact by the provider. Only the actual time of the provider's direct contact
with the patient is to be billed.  
  
 **Supportive Documentation Recommendations for contrast bath therapy**

  * Rationale requiring the unique skills of a therapist to apply, including the complicating factors
  * Area(s) being treated
  * Subjective findings to include pain ratings, pain location, effect on function

  
  
**Ultrasound therapy**  
Therapeutic ultrasound is a deep heating modality that produces a sound wave
of 0.8 to 3.0 MHz. In the human body ultrasound has several pronounced effects
on biologic tissues. It is attenuated by certain tissues and reflected by
bone. Thus, tissues lying immediately next to bone may receive as much as 30%
greater dosage of ultrasound than tissue not adjacent to bone. Because of the
increased extensibility ultrasound produces in tissues of high collagen
content, combined with the close proximity of joint capsules, tendons, and
ligaments to cortical bone where tissue may receive a more intense
irradiation, ultrasound is an ideal modality for increasing mobility in those
tissues.  
  
Covered ultrasound may be pulsed or continuous width, and should be used in
conjunction with therapeutic procedures, not as an isolated treatment.  
  
Specific indications for the use of ultrasound application include but are not
limited to:

  * limited joint motion that requires an increase in extensibility;
  * symptomatic soft tissue calcification;
  * neuromas.

  
Ultrasound application is not considered reasonable and necessary for the
treatment of:

  * asthma, bronchitis, or any other pulmonary condition;
  * conditions for which the ultrasound can be applied by the patient without the need for a therapist or other professional to administer, and/or for extended period of time (e.g., devices such as PainShield MD);
  * wounds.

  
Phonophoresis (the use of ultrasound to enhance the delivery of topically
applied drugs) will be reimbursed as ultrasound. Separate payment will not be
made for the contact medium or drugs.  
Ultrasound with electrical stimulation provided concurrently (e.g.,
Medcosound, Rich-Mar devices), should be billed as ultrasound. Do not bill for
both ultrasound and electrical stimulation for the same time period.  
If no objective and/or subjective improvement is noted after 6 treatments, a
change in treatment plan (alternative strategies) should be implemented or
documentation should support the need for continued use of ultrasound.
Documentation must clearly support the need for ultrasound more than 12
visits.  
 **Supportive Documentation Recommendations for Ultrasound Therapy**

  * Area(s) being treated
  * Frequency and intensity of ultrasound
  * Objective clinical findings such as measurements of range of motion and functional limitations to support the need for ultrasound
  * Subjective findings to include pain ratings, pain location, effect on function

  
**Hydrotherapy**  
This modality involves the patient's immersion in a tank of agitated water in
order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers,
or exfoliative skin conditions.  
  
Qualified professional/auxiliary personnel one-on-one supervision of the
patient is required. If the level of care does not require the skills of a
therapist, then the service is not covered.  
Hubbard tank treatments more than 12 visits require clear documentation
supporting the medical necessity of continued use of this modality.  
It is not medically necessary to have more than one form of hydrotherapy
during a visit.  
 **Supportive Documentation Recommendations for hydrotherapy**

  * Rationale requiring the unique skills of a therapist to apply, including the complicating factors
  * Area(s) being treated

  
Unlisted Physical therapy treatment (Specify type and time if constant
attendance)  
If an existing CPT code does not describe the service performed, an unlisted
CPT code may be used. The use of unlisted codes should be rare. If unlisted
codes are billed, the claim and medical record must clearly state what
modality or procedure is billed as an unlisted code. If not, the unlisted code
billed will be subject to denial for insufficient information.  
 _Note: Low level/cold laser light therapy (LLLT)_ is considered not
reasonable and necessary under SSA 1862(a)(1)(A) and is not payable by
Medicare. This procedure is considered non-covered billed under any HCPCS/CPT
codes, including S8948 and 97039.  
 **Supportive Documentation Recommendations for unlisted physical therapy
treatment**  
Please see the Unlisted Procedure Codes section of article A56566 Billing and
Coding: Outpatient Physical and Occupational Therapy Services, for specific
billing instructions.  
  
 **Electrical stimulation (unattended), to one or more areas for indication(s)
other than wound care, as part of a therapy plan of care  
See instructions for manual electrical stimulation.**  
Most non-wound care electrical stimulation treatment provided in therapy is
often provided in a supervised manner (after skilled application by the
qualified professional/auxiliary personnel) without constant, direct contact
required throughout the treatment.  
The code for electrical stimulation (unattended) is classified as a
"supervised" modality, even though it is labeled as "unattended." A supervised
modality does not require direct (one-on-one) patient contact by the provider.
Most electrical stimulation conducted via the application of electrodes is
considered unattended electrical stimulation. Examples of unattended
electrical stimulation modalities include Interferential Current (IFC),
Transcutaneous Electrical Nerve Stimulation (TENS), cyclical muscle
stimulation (Russian stimulation).  
These modalities should be utilized with appropriate therapeutic procedures to
effect continued improvement. Note: Coverage for this indication is limited to
those patients where the nerve supply to the muscle is intact, including
brain, spinal cord, and peripheral nerves, and other non-neurological reasons
for disuse are causing the atrophy (e.g., post-casting or splinting of a limb,
and contracture due to soft tissue scarring).  
If unattended electrical stimulation is used for control of pain and swelling,
there should be documented objective and/or subjective improvement in swelling
and/or pain within 6 visits. If no improvement is noted, a change in treatment
plan (alternative strategies) should be implemented or documentation should
support the need for continued use of this modality.  
Documentation must clearly support the need for electrical stimulation more
than 12 visits. Some patients can be trained in the use of a home TENS unit
for pain control. Only 1-2 visits should be necessary to complete the
training. Once training is completed, the electrical stimulation (unattended)
code should not be billed as a treatment modality in the clinic.  
  
 _Non-Implantable Pelvic Floor Electrical Stimulation_  
(CMS Publication 100-03, _Medicare National Coverage Determinations_ (NCD)
Manual, section 230.8.)  
 _Non-implantable pelvic floor electrical stimulators provide neuromuscular
electrical stimulation through the pelvic floor with the intent of
strengthening and exercising pelvic floor musculature._ Stimulation delivered
by vaginal or anal probes connected to an external pulse generator may be
billed with manual electrical stimulation code. Stimulation delivered via
electrodes should be billed as electrical stimulation (unattended).

  * _The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatments days per week, length of time for each treatment session, overall time period for device use, and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis.  
_

  * _Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.  
_

  * _A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of pelvic muscle exercises designed to increase periurethral muscle strength._
  * The patient's medical record must indicate that the patient receiving a non- implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training. Documentation should also include the method of delivery (e.g., probe or electrode).

  
The charges for the electrodes are included in the practice expense portion of
the electrical stimulation (unattended) code. Do not bill the Medicare
contractor or the patient for electrodes used to provide electrical
stimulation as a clinic modality.  
  
  
  
 **Supportive Documentation Recommendations for electrical stimulation
(unattended)**

  * Type of electrical stimulation used (e.g., TENS, IFC)
  * Area(s) being treated
  * If used for pain include pain rating, location of pain, effect of pain on function

  
  
**THERAPEUTIC PROCEDURES**  
  
 **General Guidelines for Therapeutic Procedures**  
  
  
Use of these procedures requires the qualified professional/auxiliary
personnel to have direct (one-on-one) patient contact. Only the actual time of
direct contact with the patient providing a service which requires the skills
of a therapist is considered for coverage. Supervision of a previously taught
exercise or exercise program, patients performing an exercise independently
without direct contact by the qualified professional/auxiliary personnel, or
use of different exercise equipment without requiring the intervention/skills
of the qualified professional/ auxiliary personnel are not covered. The
patient may be in the facility for a longer period of time, but only the time
the qualified professional/auxiliary personnel is actually providing direct,
one-on-one, patient contact which requires the skills of a therapist is
considered covered time for these procedures, and only those minutes of
treatment should be recorded.  
Under Medicare, time spent in documentation of services (medical record
production) is part of the coverage of the respective CPT code; there is no
separate coverage for time spent on documentation (except for standard
cognitive performance testing).  
The expected goals documented in the treatment plan, affected by the use of
each of these procedures, will help define whether these procedures are
reasonable and necessary. Therefore, since any one or a combination of these
procedures may be used in a treatment plan, documentation must support the use
of each procedure as it relates to a specific therapeutic goal.  
  
 **Therapeutic exercises**  
Therapeutic exercises are used for the purpose of restoring or maintaining
strength, endurance, range of motion and flexibility where loss or restriction
is a result of a specific disease or injury and has resulted in a functional
limitation. Therapeutic exercises may require active, active-assisted, or
passive participation by the patient (e.g., isokinetic exercise, lumbar
stabilization, stretching and strengthening).  
Many therapeutic exercises may require the unique skills of a therapist to
evaluate the patient's abilities, design the program, and instruct the patient
or caregiver in safe completion of the special technique. However, after the
teaching has been successfully completed, repetition of the exercise, and
monitoring for the completion of the task, in the absence of additional
skilled care, is non-covered.  
For example, as part of the initial therapy program following total knee
arthroplasty (TKA), a patient may start a session on the exercise bike to
begin gentle range of motion activity. Initially the patient requires skilled
progression in the program from pedal-rocks, building to full revolutions,
perhaps assessing and varying the seat height and resistance along the way.
Once the patient is able to safely exercise on the bike, no longer requiring
frequent assessment and progression, even if set up is required, the bike now
becomes an "independent" program and is no longer covered by Medicare. While
the qualified professional/auxiliary personnel may still require the patient
to "warm up" on the bike prior to other therapeutic interventions, it is
considered a non- skilled, unbillable service and should not be included in
the total timed code treatment minutes. _Non-skilled interventions need not be
recorded in the Treatment Notes as they are not billable._ However, notation
of non-skilled exercises may be reported if the documentation indicates that
the service was not billed (e.g., not included in the treatment minutes
documented).  
  
Exercises to promote overall fitness, flexibility, endurance (in absence of a
complicated patient condition), aerobic conditioning, weight reduction, and
maintenance exercises to maintain range of motion and/or strength are non-
covered. In addition, exercises that do not require, or no longer require, the
skilled assessment and intervention of a qualified professional/auxiliary
personnel are non-covered. Repetitive type exercises often can be taught to
the patient or a caregiver as part of a self-management, caregiver or nursing
program.  
Documentation should include not only measurable indicators such as functional
loss of joint motion or muscle strength, but also information on the impact of
these limitations on the patient's life and how improvement or maintenance in
one or more of these measures effects patient function.  
Documentation of progress should show the condition is responsive to the
therapy chosen and that the response is (or is expected to be) clinically
meaningful. Metrics of progress that are functionally meaningful (or obviously
related to clinical functional improvement) should be documented wherever
possible. For example, long courses of therapy resulting in small changes in
range of motion might not represent meaningful clinical progress benefiting
the patient's function.  
Documentation should describe new exercises added, or changes made to the
exercise program to help justify that the services are skilled. Documentation
must also show that exercises are being transitioned as clinically indicated
to an independent or caregiver- assisted exercise program ("home exercise
program" (HEP)). An HEP is an integral part of the therapy plan of care and
should be modified as the patient progresses during the course of treatment.
It is appropriate to transition portions of the treatment to an HEP as the
patient or caregiver master the techniques involved in the performance of the
exercise.  
If an exercise is taught to a patient and performed for the purpose of
restoring or maintaining functional strength, range of motion, endurance
training, and flexibility, code for strength and endurance exercise is the
appropriate code. For example, a gym ball exercise used for the purpose of
increasing the patient's strength should be considered as therapeutic exercise
when coding for billing. Also, the minutes spent taping, such as McConnell
taping, to facilitate a strengthening intervention.  
Lack of exercise equipment at home does not make continued treatment in the
clinic skilled or reasonable and necessary. The home program may need to be
carried out through community resources.  
Documentation must clearly support the need for continued therapeutic exercise
greater than 12-18 visits.  
For many patients a passive-only exercise program should not be used more than
2-4 visits to develop and train the patient or caregiver in performing PROM.
Documentation would be necessary to support services beyond this level (such
as PROM where these is an unhealed, unstable fracture, or new rotator cuff
repair, requiring the skills of a therapist to ensure that the extremity is
maintained in proper position and alignment during the PROM).  
  
  
  
 **Supportive Documentation Recommendations for therapeutic exercises**

  * Objective measurements of loss of strength and range of motion (with comparison to the uninvolved side) and effect on function
  * If used for pain include pain rating, location of pain, effect of pain on function Specific exercises performed, purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills of a therapist were required
  * When skilled cardiopulmonary monitoring is required, include documentation of pulse oximetry, heart rate, blood pressure, perceived exertion, etc.

  
**Neuromuscular re-education**  
This therapeutic procedure is provided for the purpose of restoring or
maintaining balance, coordination, kinesthetic sense, posture, and
proprioception (e.g., proprioceptive neuromuscular facilitation (PNF), BAP's
boards, vestibular rehabilitation, desensitization techniques, balance and
posture training).  
This procedure may be reasonable and necessary for restoring or maintaining
function which has been affected by:

  * loss of deep tendon reflexes and vibration sense accompanied by paresthesia, burning, or diffuse pain of the feet, lower legs, and/or fingers;
  * nerve palsy, such as peroneal nerve injury causing foot drop;
  * muscular weakness or flaccidity as result of a cerebral dysfunction, a nerve injury or disease or having had a spinal cord disease or trauma;
  * poor static or dynamic sitting/standing balance;
  * postural abnormalities;
  * loss of gross and fine motor coordination;
  * hypo/hypertonicity.

  
If an exercise/activity is taught to the patient and performed for the purpose
of restoring or maintaining functional balance, motor coordination,
kinesthetic sense, posture, or proprioception for sitting or standing
activities, code for neuromuscular re-education would be the appropriate code.
For example, a gym ball exercise used for the purpose of improving balance
should be considered as neuromuscular reeducation when coding for billing. The
minutes spent taping, such as McConnell taping or kinesiotaping techniques, to
enhance proprioception would be counted under neuromuscular re-education code.  
When therapy is instituted because there is a history of falls or a falls
screening has identified a significant fall risk, documentation should
indicate:

  * specific fall dates and/or hospitalization(s) and reason for the fall(s), if known; most recent prior functional level of mobility, including assistive device, level of assist, frequency of falls or "near-falls";
  * cognitive status;
  * prior therapy intervention;
  * functional loss due to the recent change in condition;
  * balance assessments (preferably standardized), lower extremity ROM and muscle strength testing;
  * patient and caregiver training;
  * carry-over of therapy techniques to objectively document progress.

  
It may not be reasonable and necessary to extend visits for a patient with
falls, or any patient receiving therapy services, if the purpose of the
extended visits is to:

  * remind the patient to ask for assistance;
  * offer close supervision of activities due to poor safety awareness; remind a patient to slow down;
  * offer routine verbal cues for compensatory or adaptive techniques already taught;
  * remind a patient to use an assistive device;
  * train multiple caregivers; or

  
  
In these instances, once the appropriate cues have been determined by the
qualified professional/auxiliary personnel, training of caregivers can be
provided and the care should be turned over to supportive personnel or
caregivers since repetitive cues and reminders do not require the skills of a
therapist.  
Documentation must clearly support the need for continued neuromuscular
reeducation greater than 12-18 visits.  
  
 **Supportive Documentation Recommendations for neuromuscular re-education**

  * Objective loss of ADLs, mobility, balance, coordination deficits, hypo- and hypertonicity, posture and effect on function
  * Specific exercises/activities performed (including progression of the activity), purpose of the exercises as related to function, instruction given, and/or assistance needed, to support that the skills of a therapist were required

  
  
**Aquatic therapy/exercises**  
Aquatic therapy refers to any therapeutic exercise, therapeutic activity,
neuromuscular re-education, or gait activity that is performed in a water
environment including whirlpools, hubbard tanks, underwater treadmills and
pools.  
  
This procedure may be reasonable and necessary for the loss or restriction of
joint motion, strength, mobility, balance or function due to pain, injury, or
illness by using the buoyancy and resistance properties of water.  
Aquatic therapy may be considered reasonable and necessary for a patient
without the ability to tolerate land-based exercises for rehabilitation.
Aquatic therapy exercises should be used to facilitate progression to land
based therapy. The qualified professional/personnel auxiliary personnel does
not need to be in the water with the patient unless there is an identified
safety issue.  
Exercises in the water environment to promote overall fitness, flexibility,
improved endurance, aerobic conditioning, or for weight reduction are non-
covered.  
This code should not be used in situations where no exercise is being
performed in the water environment (e.g., debridement of ulcers).  
If continued aquatic exercise is needed, the patient should be instructed in a
home program during these visits. Lack of pool facilities at home does not
make continued treatment skilled or reasonable and necessary. The home program
may need to be carried out through community resources. Documentation must
clearly support the need for aquatic therapy greater than 8 visits.  
  
Consider the following points when providing aquatic therapy services.

  * Does your patient require the skills as a therapist, or could the patient achieve their goals through a community-based aquatic exercise program? There are a limited number of therapeutic exercises generally performed in the water. These exercises become repetitive quickly. Once a patient can demonstrate an exercise safely, you may no longer bill Medicare for the time it takes the patient to perform this now independent exercise. If the same exercise is performed over a number of sessions, the documentation must describe the skilled nature of the qualified professional's/auxiliary personnel's intervention during the therapeutic exercise to support the ongoing medical necessity.
  * Patients who will not be continuing their water-based program as a maintenance program should be transitioned to land-based exercises as soon as reasonably possible for the patient's condition.
  * The aquatic therapy treatment minutes counted toward the total timed code treatment minutes should only include actual skilled exercise time that required direct one-on-one patient contact by the qualified professional/auxiliary personnel. Do not include minutes for the patient to dress/undress, get into and out of the pool, etc.
  * Do not bill for the water modality used to provide the aquatic environment, such as whirlpool in addition to aquatic therapy/exercises.
  * See Group Therapy for guidelines when treating more than one patient at the same time in the aquatic environment.

  
  
**Supportive Documentation Recommendations for Aquatic therapy/exercises**

  * Justification for use of a water environment
  * Objective loss of ADLs, mobility, ROM, strength, balance, coordination, posture and effect on function
  * If used for pain include pain rating, location of pain, effect of pain on function
  * Specific exercises/activities performed (including progression of the activity), purpose of exercises as related to function, instructions given, and/or assistance needed to perform exercises to demonstrate that the skills and of a therapist were required.

  
**Gait training therapy**  
This procedure may be reasonable and necessary for training patients and
instructing caregivers in ambulating patients whose walking abilities have
been impaired by neurological, muscular, or skeletal abnormalities or trauma.

  * Indications for gait training include, but are not limited to:
  * a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation;
  * musculoskeletal trauma, requiring ambulation reeducation;
  * a chronic, progressively debilitating condition for which safe ambulation has recently become a concern;
  * an injury or condition that requires instruction in the use of a walker, crutches, or cane;
  * a patient fitted with a brace or lower limb orthosis or prosthesis and requires instruction in ambulation;
  * a condition that requires retraining in stairs/steps or other uneven surfaces appropriate to home and community function (ramps, inclines, curbs, grass, etc);
  * instructing a caregiver in appropriate guarding and assistive techniques.

  
Gait training is not considered reasonable and necessary when the skills of a
therapist are not needed.  
Repetitive walk-strengthening exercise (such as for feeble patients or to
increase endurance or gait distance) does not require the skills of the
therapist and is considered not reasonable and necessary and is non-covered.  
Antalgic gait alone does not support the need for ongoing skilled gait
training. Antalgic gait refers to a gait pattern assumed in order to avoid or
lessen pain. Limited gait training may be appropriate, when supported as
medically necessary in the documentation, to teach the patient improved gait
patterns to reduce the stress on the painful area. In most circumstances, as
the pain decreases (with or without skilled therapy intervention) the gait
will improve spontaneously without the need for skilled gait training
intervention.  
  
Documentation must clearly support the need for continued gait training beyond
12-18 visits within a 4-6 week period.  
  
 _Neuromuscular Electrostimulation - Use for Walking in Patients with Spinal
Cord Injury (SCI)  _ \- _The type of NMES that is used to enhance the ability
to walk of SCI patients is commonly referred to as functional electrical
stimulation (FES). These devices are surface units that use electrical
impulses to activate paralyzed or weak muscles in precise sequence. Coverage
for the use of NMES/FES is limited to SCI patients, for walking, who have
completed a training program, which consists of at least 32 physical therapy
sessions with the device over a period of 3 months. The trial period of
physical therapy will enable the physician treating the patient for his or her
spinal cord injury to properly evaluate the person's ability to use these
devices frequently and for the long term. Physical therapy necessary to
perform this training must be directly performed by the physical therapist as
part of a one-on-one training program.  
The goal of physical therapy must be to train SCI patients on the use of
NMES/FES devices to achieve walking, not to reverse or retard muscle atrophy.  
Coverage for NMES/FES for walking will be covered in SCI patients with all of
the following characteristics:  
1\. Persons with intact lower motor units (L1 and below) (both muscle and
peripheral nerve);  
2\. Persons with muscle and joint stability for weight bearing at upper and
lower extremities that can demonstrate balance and control to maintain an
upright support posture independently;  
3\. Persons that demonstrate brisk muscle contraction to NMES and have sensory
perception [of] electrical stimulation sufficient for muscle contraction;  
4\. Persons that possess high motivation, commitment and cognitive ability to
use such devices for walking;  
5\. Persons that can transfer independently and can demonstrate independent
standing tolerance for at least 3 minutes;  
6\. Persons that can demonstrate hand and finger function to manipulate
controls;  
7\. Persons with at least 6-month post recovery spinal cord injury and
restorative surgery;  
8\. Persons with[out] hip and knee degenerative disease and no history of long
bone fracture secondary to osteoporosis; and  
9\. Persons who have demonstrated a willingness to use the device long-term._  
(Italicized information about NMES for walking in SCI patients is from CMS
Publication 100-03, _Medicare National Coverage Determinations_ (NCD) Manual,
section 160.12)  
  
ICD-10-CM diagnosis code for paraplegia must be present for payment to be
made. However, while paraplegia of lower limbs is a necessary condition for
coverage, the nine criteria above are also required.  
The code for gait training is the only code to be billed. It must be used for
one-on-one face-to-face service provided by the physician or therapist.  
  
 **Supportive Documentation Recommendations for gait training**

  * Objective measurements of balance and gait distance, assistive device used, amount of assistance required, gait deviations and limitations being addressed, use of orthotic or prosthesis, need for and description of verbal cueing
  * Presence of complicating factors (pain, balance deficits, gait deficits, stairs, architectural or safety concerns)
  * Specific gait training techniques used, instructions given, and/or assistance needed, and the patient's response to the intervention, to demonstrate that the skills of a therapist were required

  
**Massage therapy** Massage may be medically necessary as adjunctive treatment
to another therapeutic procedure on the same day, which is designed to reduce
edema, improve joint motion, or relieve muscle spasm.  
Massage chairs, aquamassage tables and roller beds are not considered massage.
These services are non-covered.  
Massage is not covered as an isolated treatment.  
Documentation must clearly support the need for continued massage beyond 6-8
visits, including instruction, as appropriate, to the patient and caregiver
for continued treatment.  
This code is not covered on the same visit date as manual therapy techniques.  
Do not bill massage therapy for percussion for postural drainage.  
 **Supportive Documentation Recommendations for massage therapy**

  * Area(s) being treated
  * Objective clinical findings such as measurements of range of motion, description of muscle spasms and effect on function
  * Subjective findings including pain ratings, pain location, effect on function

  
  
**Physical medicine procedure**  
If an existing CPT code does not describe the service performed, an unlisted
CPT code may be used. The use of unlisted codes should be rare. If unlisted
codes are billed, the claim and medical record must clearly state what
modality or procedure is billed as an unlisted code. If not, the unlisted code
billed will be subject to denial for insufficient information.  
  
 **Supportive Documentation Recommendations for physical medicine procedure**  
Please see section Documentation Recommendations for Unlisted Procedure Codes.  
Please see the Unlisted Procedure Codes section of article A56566 Billing and
Coding: Outpatient Physical and Occupational Therapy Services , for specific
billing instructions.  
  
 **Manual therapy**

  * _Manual traction_ may be considered reasonable and necessary for cervical dysfunctions such as cervical pain and cervical radiculopathy.
  * _Joint Mobilization_ (peripheral and/or spinal) may be considered reasonable and necessary if restricted or painful 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.
  * _Myofascial release/soft tissue mobilization_ , one or more regions, may be reasonable and necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems.
  * _Manipulation_ , which is a high-velocity, low-amplitude thrust technique or Grade V thrust technique, may be reasonable and necessary for treatment of painful spasm or restricted motion in the periphery, extremities or spinal regions.
  * _Manual lymphatic drainage/complex decongestive therapy (MLD/CDT)_ MLD / CDT is indicated for both primary and secondary lymphedema. Lymphedema in the Medicare population is usually secondary lymphedema, caused by known precipitating factors. Common causes include surgical removal of lymph nodes, fibrosis secondary to radiation, and traumatic injury to the lymphatic system.

  
Both primary and secondary lymphedemas are chronic and progressive conditions
which can often (but not always) be brought under long-term control with
proper management. By maintaining control of the lymphedema, patients can:

  * restore a normal, or near-normal, shape;
  * reduce the potential for complications (e.g., cellulitis, lymphangitis, deformity, injury, fibrosis, lymphangiosarcoma (rare), etc.);
  * reduce functional deficits to resume activities of daily living.

  
MLD/CDT consists of skin care, manual lymph drainage, compression wrapping,
and therapeutic exercises. Coverage of MLD / CDT would only be allowed if all
of the following conditions have been met:

  * there is a physician-documented diagnosis of lymphedema (primary or secondary);
  * the patient has documented signs or symptoms of lymphedema;
  * the patient or patient caregiver has the ability to understand and comply with the continuation of the treatment regimen at home.

  
The goal of treatment is to reduce lymphedema of an extremity by routing the
fluid to functional pathways, preventing backflow as the new routes become
established, and to use the most appropriate methods to maintain such
reduction of the extremity after therapy is complete. This therapy involves
intensive treatment to reduce the volume by a combination of manual
decongestive therapy and serial compression bandaging, followed by an exercise
program. Ultimately the plan must be to transfer the responsibility of care
from the therapist to management by the patient, patient's family, or
patient's caregiver.

  * In moderate to severe lymphedema, daily visits are usually required for the first 3-8 weeks.
  * Education should be provided to the patient and/or caregiver on the correct application of the compression bandage.
  * The therapeutic exercise component for MLD / CDT is covered under CPT code therapeutic procedure;strength and endurance.

  
MLD/CDT is not covered for:

  * conditions reversible by exercise or elevation of the affected area;
  * dependent edema related to congestive heart failure or other cardiomyopathies;
  * patients who do not have the physical and cognitive abilities, or support systems, to accomplish self-management in a reasonable time;
  * continuing treatment for a patient non-compliant with a program for self- management.

  
Documentation must clearly support the need for continued manual therapy
treatment beyond 12-18 visits. When the patient and/or caregiver has been
instructed in the performance of specific techniques, the performance of these
same techniques should not be continued in the clinic setting and counted as
minutes of skilled therapy.  
Massage therapy  is not covered on the same visit as this code.  
 **Supportive Documentation Recommendations for Manual therapy**

    * Area(s) being treated
    * Soft tissue or joint mobilization technique used
    * Objective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on function
    * For MLD/CDP, supportive documentation should include:  

      * medical history related to onset, exacerbation and etiology of the lymphedema
      * comorbidities prior treatment
      * cognitive and physical ability of patient and/or caregiver to follow self- management techniques;
      * pain/discomfort descriptions and ratings;
      * limitation of function related to self-care, mobility, ADLs and/or safety; prior level of function;
      * limb measurements of affected and unaffected limbs at start of care and periodically throughout treatment;
      * description of skin condition, wounds, infected sites, scars.

  
  
**Group therapeutic procedures Report  the group therapy code for each member
of the group. Group therapy procedures involve constant attendance of the
physician, NPP, therapist, or assistant, but by definition do not require one-
on-one patient contact.**  
 _Group therapy consists of therapy treatment provided simultaneously to two
or more patients who may or may not be doing the same activities. If the
therapist is dividing attention among the patients, providing only brief,
intermittent personal contact, or giving the same instructions to two or more
patients at the same time,_ one unit is appropriate per patient.  
  
Examples:

  * _In a 25-minute period, a therapist works with two patients, A and B, and divides his/her time between the two patients. The therapist moves back and forth between the two patients, spending a minute or two at a time, and provides occasional assistance and modifications to patient A 's exercise program and offers verbal cues for patient B's gait training and balance activities on the parallel bars. The therapist does not track continuous identifiable episodes of direct one-on-one contact with either patient. The appropriate coverage is one (1) unit for each patient.  
_

  * _In a 45-minute period, a therapist works with 3 patients - A, B, and C - providing therapeutic exercises to each patient with direct one-on-one contact in the following sequence: Patient A receives 8 minutes, patient B receives 8 minutes and patient C received 8 minutes. After this initial 24-minute period, the therapist returns to work with patient A for 10 more minutes (18 minutes total), then patient B for 5 more minutes (13 minutes total), and finally patient C for 6 additional minutes (14 minutes total). During the times the patients are not receiving direct one-on-one contact with the therapist, they are each exercising independently. The therapist appropriately bills each patient one 15 minute unit of therapeutic exercise_.

  
Supervision of a previously taught exercise program or supervising patients
who are exercising independently is not a skilled service and is not covered
as group therapy or as any other therapeutic procedure. Supervision of
patients exercising on machines or exercise equipment, in the absence of the
delivery of skilled care, is not a skilled service and is not covered as group
therapy or as any other therapeutic procedure.  
  
Non-covered as group therapy

  * Groups directed by a student, therapy aide, rehabilitation technician, nursing aide, recreational therapist, exercise physiologist, or athletic trainer
  * Routine (i.e., supportive) groups that are part of a maintenance program, nursing rehabilitation program, or recreational therapy program
  * Groups using biofeedback for relaxation
  * Viewing videotapes; listening to audiotapes
  * Group treatment that does not require the unique skills of a therapist

  
If group therapy is billed on a given day, it must be listed in the Treatment
Note. The minutes of this untimed code must be added to the Total Treatment
Time for that day. Further documentation describing the skilled nature of the
group session documented in the progress report or the treatment note may
assist in supporting the medical necessity of the service.  
  
 **Supportive Documentation Recommendations for group therapy**

  * The purpose of the group and the number of participants in the group
  * Description of the skilled activity provided in the group setting, such as instruction in proper form, or upgrading the difficulty of the activity for an individual.

  
**Therapeutic activities**  
Therapeutic activities are considered reasonable and necessary for patients
needing a broad range of rehabilitative techniques that involve movement.
Movement activities can be for a specific body part or could involve the
entire body. This procedure involves the use of functional activities (e.g.,
bending, lifting, carrying, reaching, catching, pushing, pinching, grasping,
transfers, bed mobility and overhead activities) to restore or maintain
functional performance. The activities are usually directed at a loss or
restriction of mobility, strength, balance, or coordination. They require the
skills of the therapist to design the activities to address a specific
functional need of the patient and to instruct the patient in their
performance. These dynamic activities must be part of an active treatment plan
and must be directed at a specific outcome.  
  
In order for therapeutic activities to be covered, the following requirements
must be met:

  * the patient has a documented condition for which therapeutic activities can reasonably be expected to restore or maintain functioning;
  * there is a clear correlation between the type of therapeutic activity performed and the patient's underlying medical condition;
  * the patient's condition is such that he/she is unable to perform the therapeutic activities without the skilled intervention of the qualified professional/auxiliary personnel.

  
Documentation must clearly support the need for continued therapeutic activity
treatment beyond 10-12 visits.  
 **Supportive Documentation Recommendations for therapeutic activities**

  * Objective measurements of loss of ADLs, balance, strength, coordination, range of motion, mobility and effect on function
  * Specific activities performed, and amount and type of assistance to demonstrate that the skills and expertise of the therapist were required

  
**Cognitive skills development**  
This activity is designed to improve attention, memory, and problem-solving,
including the use of compensatory techniques. Cognitive skill training may be
medically necessary for patients with acquired cognitive deficits resulting
from head trauma, or acute neurologic events including cerebrovascular
accidents. Impaired functions may include but are not limited to ability to
follow simple commands, attention to tasks, problem solving skills, memory,
ability to follow numerous steps in a process, perform in a logical sequence
and ability to compute.  
Evidence-based reviews indicate that cognitive rehabilitation (and
specifically memory rehabilitation) is not recommended for patients with
severe cognitive dysfunction.  
Cognitive skill training should be aimed towards specific functions which were
impaired by an identified illness or injury, and expected outcomes should be
reasonably attainable by the patient as specified by the plan of care.  
Cognitive skills are an important component of many tasks, and the techniques
used are integral to the broader impairment being addressed. Cognitive therapy
techniques are most often covered as components of other therapeutic
procedures, and, typically are better reported using other codes (such as
97535).  
Activities billed as cognitive skills development include only those that
require the skills of a therapist and must be provided with direct (one-on-
one) contact between the patient and the qualified professional/auxiliary
personnel. Those services that a patient may engage in without a skilled
therapist qualified professional/auxiliary personnel are not covered under the
Medicare benefit.  
Coverage is limited to the following conditions.

  * Personality change due to known physiological condition
  * Other personality and behavioral disorders due to known physiological condition
  * Pseudobulbar affect
  * Unspecified mental disorder due to known physiological condition
  * Unspecified personality and behavioral disorder due to known physiological condition

  
Please also add the ICD-10-CM code for the underlying disorder (cause). Note:
the restrictions placed upon this code do not apply to vision impairment
rehabilitation services as defined in PM AB-02-078.  
 **Supportive Documentation Recommendations for Cognitive skills development**

  * Objective assessment of the patient's cognitive impairment and functional abilities
  * A determination of a range of compensatory strategies that the individual can realistically utilize to in a meaningful way
  * Specific cognitive activities performed, amount of assistance, and the patient's response to the intervention, to demonstrate that the skills and expertise of the therapist were required

  
**Sensory integration**  
Sensory integrative techniques are performed to enhance sensory processing and
promote adaptive responses to environmental demands. These treatments are
performed when a deficit in processing input from one of the sensory systems
(e.g., vestibular, proprioceptive, tactile, visual or auditory) decreases an
individual's ability to make adaptive sensory, motor and behavioral responses
to environmental demands.  
Individuals in need of sensory integrative treatments demonstrate a variety of
problems, including sensory defensiveness, over-reactivity to environmental
stimuli, attention difficulties, and behavioral problems.  
Sensory integration treatments are often associated with pediatric
populations. For non- pediatric patients, these services may be medically
necessary for acquired sensory problems resulting from head trauma, illness,
or acute neurologic events including cerebrovascular accidents. Therapy is not
considered a cure for sensory integrative impairments, but is used to
facilitate the development of the nervous system's ability to process sensory
input differently.  
Utilization of this service should be infrequent for Medicare patients.  
 **Supportive Documentation Recommendations for sensory integration**

  * Objective assessments of the patient's sensory integration impairments and functional limitations
  * Describe the treatment techniques used that will promote adaptive responses to environmental demands, and the patient's response to the intervention, to support that the skills of a therapist were required

  
**Self -care management training**  
This procedure is reasonable and necessary only when it requires the skills of
a therapist, is designed to address specific needs of the patient, and is part
of an active treatment plan directed at a specific outcome.  
The patient must have a condition for which self-care/home management training
is reasonable and necessary. The training should be focused on a functional
limitation(s) that will be meaningful to the patient and the caregiver. The
patient and/or caregiver must have the capacity and willingness to learn from
instructions. Documentation must relate the training to expected functional
goals.  
This code should be used for activities of daily living (ADL) and compensatory
training for ADL, safety procedures, and instructions in the use of adaptive
equipment and assistive technology for use in the home environment. See more
specific codes for exercise training, orthotics, gait devices, etc.  
This code should not be used globally for all home instructions. When
instructing the patient in a self management program, use the code that best
describes the focus of the self management activity.  
Services provided to the same patient by physical therapy and occupational
therapy may be covered if separate and distinct goals are documented in the
treatment plans and there is no duplication of services.  
Many ADL/IADL impairments may require the unique skills of a therapist to
evaluate the patient's abilities, design the program and instruct the patient
or caregiver in safe completion of the special technique. However, repetitious
completion of the activity, once taught and monitored, is non-covered care.  
For example, as part of the initial occupational therapy program following a
total hip arthroplasty (THA), a patient may need to learn adaptive lower
extremity dressing techniques due to pain, limited ROM and hip precautions.
The occupational therapist will need to evaluate the patient to determine the
appropriate technique to be taught based on the patient's unique assessment
and will instruct the patient and/or caregiver in the special technique. Once
the special dressing technique has been taught and monitored for safe
completion, repetitious carrying out or practicing of the dressing technique
would be considered non-skilled and would not be covered. Non-skilled
interventions need not be recorded in the Treatment Notes as they are not
billable. However, notation of non-skilled activities may be reported if the
documentation indicates that the service was not billed (e.g., not included in
the treatment minutes documented).  
  
As the patient progresses through an episode of care involving self care/home
management training, documentation needs to clearly support that the skills of
a therapist continue to be necessary. It is important that documentation
demonstrates that the skills of a therapist are needed and that the patient is
not merely practicing techniques that have already been taught.  
  
 **Supportive Documentation Recommendations for self-care management**

  * Objective measurements of the patient's activity of daily living (ADL)/instrumental activity of daily living (IADL) impairment to be addressed
  * The specific ADL and/or compensatory training provided, specific safety procedures addressed, specific adaptive equipment/assistive technology utilized, instruction given and assist required (verbal or physical), and the patient's response to the intervention, to support that the services provided required the skills and expertise of a therapist

  
**Community/work reintegration**  
For wheelchair management/propulsion training use appropriate wheelchair
management CPT code.  
This code should be utilized when a patient is trained in the use of assistive
technology to assist with mobility, seating systems and environmental control
systems for use in the community.  
General activity programs, and all activities which are primarily social or
diversional in nature, will be denied because the professional skills of a
therapist are not required. Services must be necessary for medical treatment
of an illness or injury rather than related solely to specific leisure or
employment opportunities, work skills or work settings.  
Coverage greater than 4-6 visits for community training should be justified by
documentation to show the medical necessity of the length of treatment.  
 **Supportive Documentation Recommendations for Community/work reintegration**

  * Objective measurements of the patient's community IADL impairment to be addressed
  * Specific training provided, amount of assist required (verbal or physical), and the patient's response to the intervention, to support that the services rendered required the skills of a therapist

  
**Wheelchair management training**  
This code is used to reflect the skilled wheelchair management intervention
clinicians provide related to the assessment, fitting and/or training for
patients who must utilize a wheelchair for mobility. This service trains the
patient, family and/or caregiver in functional activities that promote safe
wheelchair mobility and transfers. Patients who are wheelchair bound may
occasionally need skilled input on positioning to avoid pressure points,
contractures, and other medical complications.  
CPT Changes 2006 - An Insider's View provides further clarification regarding
the assessment portion of this code. A wheelchair assessment may include but
is not limited to the patient's strength, endurance, living situation, ability
to transfer in and out of the chair, level of independence, weight, skin
integrity, muscle tone, and sitting balance. Following verification of the
patient's need, patient measurements are taken of the patient prior to
ordering the equipment to ensure accuracy of sizing wheelchair components.
This measurement may also involve testing the patient's abilities with various
chair functions including propulsion, transferring from the chair to other
surfaces (bed, toilet, car), and use of the chair's locking mechanism on
various types of equipment for optimal determination of the appropriate
equipment by the patient and caregiver.  
For example, when assessing and fitting the patient with a wheelchair and
custom seating system to provide stabilization, support, balance, and pressure
management. Would also be used when training the patient in the safe operation
and management of the wheelchair in the home and community environment. (This
example is based upon the Clinical Example for in the CPT Changes 2006 - an
Insider's View.)  
There may be circumstances where a patient may be seen one time for a
wheelchair assessment. If it is not necessary to complete a full patient
evaluation, but only an assessment related to specific wheelchair needs, this
one-time only session may be billed with the appropriate units reflecting the
time spent in the assessment.  
For many patient situations however, a full patient evaluation is needed to
develop the appropriate treatment plan in addition to wheelchair fitting and
training. In these situations, it may be appropriate to bill the initial
evaluation code. On the day that the evaluation code is billed, the minutes
assigned to wheelchair management should only be related to any wheelchair
fitting and training provided, as this is a timed code. For example, if a
physical therapist spends 35 minutes gathering the patient history, prior
functional status, current functional status, social considerations, range of
motion, strength, sensation, balance, and transfers, this time would be
assigned to the PT initial evaluation. As the session continues, the PT spends
45 minutes assessing the patient in a variety of wheelchair set ups, trying a
variety of adaptations to best meet the patient's comfort and functional
needs, and initiates training with the patient and family, this 45 minutes
would be assigned to the wheelchair management code.  
  
  
Consider the following points when providing wheelchair management services.

  * Assessment for cushions, lapboards, wheelchair trays, or lap buddies for a patient _without a complicating condition_ typically does not require the unique skills of a therapist.
  * A seating assessment is not medically necessary for every patient.
  * Skilled intervention would not be necessary for wheelchair issues that the patient can self-correct.
  * The patient/caregiver must have the capacity and willingness to learn from instructions.
  * When wheelchair and seating assessments are reasonable, care should be turned over to supportive personnel or a caregiver once the necessary modifications are successfully implemented.
  * Ongoing visits for increasing sitting times are generally not reasonable and necessary when no patient problems are documented.
  * Visits made for restraint reduction are generally non-covered.
  * It is expected that multiple wheelchair and seating deficits discovered during the initial evaluation would be treated concurrently. If not, documentation must indicate that a new problem/deficit occurred, or include rationale why a problem being treated in the later stages of therapy was not addressed previously.

  
Typically up to 3-4 dates of service should be sufficient to train the
patient/caregiver in wheelchair management. Coverage beyond this utilization
should have supportive documentation that clearly demonstrates the need for
additional visits.  
 **Supportive Documentation Recommendations for wheelchair management**

    * Documentation for a skilled wheelchair assessment should include the following:   

      * the recent event that prompted the need for a skilled wheelchair assessment; any previous wheelchair assessments have been completed, such as during a Part A SNF stay;
      * most recent prior functional level;
      * if applicable, any previous interventions that have been tried by nursing staff, caregivers or the patient that may have failed, prompting the initiation of skilled therapy intervention;
      * functional deficits due to poor seating or positioning;
      * objective assessments of applicable impairments such as range of motion (ROM), strength, sitting balance, skin integrity, sensation and tone;
      * the response of the patient or caregiver to the fitting and training.



  * When billing for wheelchair management/training, documentation must relate the training to expected functional goals that are attainable by the patient and /or caregiver.
  * Describe the interventions to show that the skills of a therapist were required. For example, describe the various wheelchair adaptations trialed and the patient's response to the intervention. If training is provided, describe the type of training, the amount of assistance required and the patient response to the training.

  
**Work hardening/conditioning and  each additional hour**  
These services are related solely to specific work skills and will be denied
as not medically necessary for the diagnosis or treatment of an illness or
injury.

  
**  Rmvl devital tis 20 cm/<  
 Rmvl devital tis addl 20 cm<  
Wound(s) care non-selective  
**  
Active wound care procedures are performed to remove devitalized tissue and
promote healing, and involve selective and non-selective debridement
techniques. Debridement is indicated whenever necrotic tissue is present in an
open wound. Debridement may also be indicated in cases of abnormal wound
healing or repair. Debridement will not be considered a reasonable and
necessary procedure for a wound that is clean and free of necrotic tissue.  
The wound care performed must be in accordance with accepted standards of
medical practice. If debridement is performed, the type of debridement should
be appropriate to the type of wound and the devitalized tissue, and the
patient's condition. Not all wounds require debridement at each session or the
same level of debridement at each session. It is unusual to debride more than
one time per week for more than three months. A greater frequency or duration
of selective debridement should be justified in the documentation. Most very
small wounds do not require selective debridement. Ulcers that may require
selective debridement are typically larger than 2 x 2 cm. Wounds with
tunneling, regardless of size, may require selective debridement. Selective
debridement is usually not reasonable and necessary for blisters, ulcers
smaller than those described above and uninfected ulcers with clear borders.  
Documentation for each treatment must include a detailed description of the
procedure and the method (e.g., scalpel, scissors, 4x4 gauze, wet-to-dry,
enzyme). Because the correct debridement code is dependent on type of
debridement and wound size, documentation should include frequent wound
measurements. The documentation should also include a description of the
appearance of the wound (especially size, but also depth, stage, bed
characteristics), as well as the type of tissue or material removed. The
documentation must meet the criteria of the code billed.  
Medicare coverage for wound care on a continuing basis for a particular wound
requires documentation in the patient's record that the wound is improving in
response to the wound care being provided. It is not medically reasonable or
necessary to continue a given type of wound care if evidence of wound
improvement cannot be shown.  
  
Evidence of improvement includes measurable changes (decreases) in at least
some of the following:

  * drainage;
  * inflammation;
  * swelling; pain;
  * wound dimensions (diameter, depth);
  * necrotic tissue/slough.

  
Such evidence must be documented periodically (e.g. weekly.) A wound that
shows no improvement after 30 days requires a new approach, which may include
a physician/NPP reassessment of underlying infection, metabolic, nutritional,
or vascular problems inhibiting wound healing, or a new treatment approach.  
In rare instances, the goal of wound care provided in outpatient settings may
be only to prevent progression of the wound, which, due to severe underlying
debility or other factors such as inoperability, is not expected to improve.
If this is the case, documentation should clearly indicate this rationale for
continued skilled wound care.  
 _Examples of Selective Debridement_ (without anesthesia)

  * Conservative Sharp Debridement: Conservative sharp debridement is a minor procedure that requires no anesthesia. Scalpel, scissors, forceps, or tweezers may be used and only clearly identified devitalized tissue is removed. Generally, there is no bleeding associated with this procedure.
  * High Pressure Water Jet Lavage: (non-immersion hydrotherapy) is an irrigation device, with or without pulsation used to provide a water jet to administer a shearing effect to loosen debris, within a wound. Some electric pulsatile irrigation devices include suction to remove debris from the wound after it is irrigated.

  
_Examples of Non-Selective Debridement_ (without anesthesia)  include the
following items.

  * Blunt debridement
  * Blunt debridement involves the removal of necrotic tissue by cleansing or scraping (abrasion). It may also involve the cleaning and dressing of small or superficial lesions. 
    * Enzymatic debridement
    * Debridement with topical proteolytic enzymes is used as an adjunctive therapy in treating chronic wounds. The manufacturers' product insert contains indications, contraindications, precautions, dosage and administration guidelines; it is the clinician's responsibility to comply with those guidelines. 
  * Wet-to-moist dressings
  * 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. 
  * Autolytic and chemical debridement

  
Additional guidance for debridement codes

  * These codes are not timed.
  * Do not bill for more than one unit per session, regardless of the number or complexity of the wounds treated.
  * Do not bill for both selective wound debridement and devitalized tissue for the same wound.
  * Use the -59 modifier to indicate nonselective and selective debridement provided in a single encounter at different anatomical sites.
  * Application and removal of dressings to the wound is included in the work and practice expenses and should not be billed separately under a therapy plan of care. Charges for dressings, gauze, tape, sterile water for irrigation, tweezers, scissors, q-tips, and medications used in the wound care treatment will be denied even if the wound care service is found to be medically reasonable and necessary. Payment for dressings applied to the wound is included and they are not to be billed separately. If a simple dressing change is performed without any active wound procedure as described by these codes, do not bill these codes to describe the service.
  * For wound assessment it is not appropriate to bill therapy re-evaluation codes along with codes the selective wound debridement and devitalized tissue codes. The assessment, including measurements of the wound and a written report, is considered a part of the codes.
  * Whirlpool and selective wound debridement  should not be billed together as the whirlpool treatment is a component of the selective wound debridement code (unless there is a separately identifiable condition being treated and documentation supports this treatment).
  * Patient and caregiver instructions are included in the codes. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.
  * These codes represent "sometimes therapy" services and will be paid under the OPPS when (a) the service is not performed by a therapist, and (b) it is inappropriate to bill the service under a therapy plan of care. Nurses performing debridement (where allowed by state scope of practice acts) described by codes for selective wound debridement and devitalized tissue may bill these codes using revenue codes other than the therapy revenue codes 42x (PT) and 43x (OT).
  * Payment for devitalized tissue, when performed by a qualified professional/auxiliary personnel under a therapy plan of care, is recognized as a bundled service under the Medicare Physician Fee Schedule (MPFS). Regardless of whether billed alone or in conjunction with another therapy code, separate payment is never made.
  * Evaluation and management services should not be billed along with the debridement service unless a significant, separately identifiable evaluation and management service, correctly identified with modifier -25 on the claim, was also provided to the patient during the same encounter. (Therapists should not use the evaluation and management codes at any time.)

  
**Supportive Documentation Recommendations for selective wound debridement and
devitalized tissue**

  * Etiology and duration of wound
  * Prior treatment by a physician, non-physician practitioner, nurse and/or therapist Stage of wound
  * Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate
  * Evidence of infection, undermining, or tunneling Nutritional status
  * Comorbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use
  * Patient's functional level
  * Skilled plan of treatment, including specific frequency, modalities and procedures Type of debridement performed, including instrument used, to support the debridement code billed
  * Changing plan of treatment based on clinical judgment of the patient's response or lack of response to treatment
  * Frequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.

  
Note: While debridement is considered a covered service for appropriately
selected wounds, the following services are considered non-covered for the
treatment of wounds.

  * Topical application of oxygen (CMS Publication 11-03, Medicare National Coverage Determinations (NCD) Manual, section 270.4.)
  * Ultrasound
  * Infrared and/or near-infrared light and/or heat, including monochromatic infrared energy (MIRE) (CMS Publication 11-03, Medicare National Coverage Determinations (NCD) Manual, section 270.6.)
  * Low Level Laser Treatment (LLLT) Magnet therapy
  * Autologous blood-derived products for chronic, non-healing wounds (CMS Publication 11-03, _Medicare National Coverage Determinations_ (NCD) Manual, section 270.3.)
  * Routine dressing changes
  * Non-Contact Normothermic Wound Therapy (NNWT) (CMS Publication 11-03, _Medicare National Coverage Determinations_ (NCD) Manual, section 270.2.)

  
  
  
**Neg press wound tx < 50 cm CPT**

**Neg press wound tx > 50 cm **

**Neg press wound tx <50cm **

**Neg press wound tx >50 cm**  
  
  
Negative pressure wound therapy (NPWT) involves negative pressure to the wound
bed to manage wound exudates and promote wound healing. The FDA defines a
system that promotes healing in various types of open wounds by removing wound
fluids and waste materials (debris) through the creation of a vacuum (negative
pressure) at a well-sealed wound site. NPWT may also help with wound healing
by drawing wound edges together.  
NPWT systems consist of the following parts: a pump that generates a vacuum
and is capable of creating a negative pressure environment within a sealed
wound; dressing materials used to pack the wound and seal it; tubing for fluid
removal from the wound area; and a container/canister to collect waste
materials that are removed from the wound area by suction.  
NPWT is indicated for use as an adjunct to standard treatment in carefully
selected patients who have failed all other forms of treatment. NPWT may be
indicated for wounds such as:

  * Stage III or IV pressure ulcers;
  * Neuropathic (for example, diabetic) ulcers;
  * Chronic arterial or venous insufficiency ulcers;
  * Complications of surgically created or traumatic wounds.

  
NPWT is not covered for:

  * Stage I or II pressure ulcers;
  * Wounds with eschar present;
  * Untreated osteomyelitis within the vicinity of the wound;
  * Malignancy present in the wound;
  * Exposed vasculature;
  * Exposed nerve(s);
  * Exposed anastomotic site;
  * Exposed organ(s);
  * Active bleeding;
  * The presence of a fistula to an organ or body cavity within the vicinity of the wound.

  
  
**The FDA has issued a Safety Communication titled "UPDATE on Serious
Complications Associated with Negative Pressure Wound Therapy Systems" dated
24 February 2011.**  
Any provider using NPWT therapy should be fully aware of the findings and
recommendations contained therein. An internet link to this communication may
be found under the Sources of Information and Basis for Decision header below.  
  
Additional guidance for NPWT codes

  * These codes are not timed.
  * Do not bill for more than one unit per session, regardless of the number or complexity of the wounds treated.
  * Patient and caregiver instructions are included in the codes. Do not bill separately under any other code for instructing the patient/caregiver in care of the wound.
  * It is not appropriate to bill therapy re-evaluation codes along with Negative Pressure Wound Therapy Systems. The assessment, including measurements of the wound and a written report, is considered a part of the code.

  
**Supportive Documentation Recommendations for Negative Pressure Wound Therapy
Systems**

  * Etiology and duration of wound
  * Prior treatment by a physician, non-physician practitioner, nurse and/or therapist Stage of wound
  * Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate
  * Evidence of infection, undermining, or tunneling Nutritional status
  * Comorbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use
  * Patient's functional level
  * Skilled plan of treatment, including specific frequency, modalities and procedures Changing plan of treatment based on clinical judgment of the patient's response or lack of response to treatment
  * Frequent skilled observation and assessment of wound healing are recommended daily or weekly to justify the skilled service. At a minimum, the Progress Report must document the continuing skilled assessment of wound healing as it has progressed since the evaluation or last Progress Report.

  
**Physical performance test**  
Physical performance testing may be reasonable and necessary for patients with
neurological, musculoskeletal, or pulmonary conditions. These tests and
measurements are beyond the usual evaluation services performed. Examples of
physical performance tests or measurements include isokinetic testing,
Functional Capacity Evaluation (FCE) and Tinetti. This code may be used for
the 6-minute walk test, with a computerized report of the patient's oxygen
saturation levels with increasing stress levels, performed under a PT or OT
plan of care on pulmonary rehabilitation patients.  
The therapy evaluation and re-evaluation codes are for a comprehensive review
of the patient including, but not limited to, history, systems review, current
clinical findings, establishment of a therapy diagnosis, and estimation of the
prognosis and determination and/or revision of further treatment. The physical
performance test is intended to focus on patient performance of a specific
activity or group of activities (CPT Assistant, December 2003).  
There must be written evidence documenting the problem requiring the test, the
specific test performed, and a separate measurement report. This report may
include torque curves and other graphic reports with interpretation.  
It is not reasonable and necessary for the test to be performed and billed on
a routine basis (i.e., monthly or instead of billing a reevaluation) or to be
routinely performed on all patients treated. It should not be used to bill for
patient assessments/re- assessments such as ROM testing or manual muscle
testing completed at the start of care (as this is typically part of the
examination included in the initial evaluation) and/or as the patient
progresses through the episode of treatment.  
  
 **Supportive Documentation Recommendations for  physical performance test **

  * Problem requiring the test and the specific test performed
  * Separate measurement report, including any graphic reports
  * Application to functional activity
  * How the test impacts the plan of care

  
  
**Assistive technology assess**  
The provider performs an assessment of the suitability and benefits of
acquiring any assistive technology device or equipment that will help restore,
augment, or compensate for existing functional ability in the patient (e.g.,
provision of large amounts of rehabilitative engineering).  
Coverage is specifically for assessment of mobility, seating and environmental
control systems that require high level adaptations, not for routine seating
and mobility systems (e.g., manual/power wheelchair evaluations).  
This is an assessment code, per each 15 minutes, and must be accompanied by a
written report explaining the nature and complexity of the assistive
technology needed by the patient. This can include testing multiple
components/systems to determine optimal interface between client and
technology applications, and determining the appropriateness of commercial
(off the shelf) or customized components/systems. This assessment may require
more than one patient visit due to the complexity of the patient's condition
and his/her decreased tolerance for activity at one session.  
Training for use in assistive technology in the home environment has a
different code for use in the community.  
  
Utilization of this service should be infrequent.  
 **Supportive Documentation Recommendations for Assistive technology assess**

  * The goal of the assessment
  * The technology/component/system involved
  * A description of the process involved in assessing the patient's response
  * The outcome of the assessment
  * Documentation of how this information affects the treatment plan

  
  
**Orthotic management and training**  
Gait training for the use of the orthotic is included in the fee for orthotic
management and training. If gait training is necessary for purposes other than
the use of the orthotic then the documentation shall clearly show the reasons
for same.  
  
An orthotic is a brace that includes rigid and semi-rigid components that are
used for the purpose of supporting a weak or deformed body member or
restricting or eliminating motion in a diseased or injured part of the body.
(Elastic stockings, garter belts, neoprene braces and similar devices do not
come within the scope of the definition of a brace.) HCFA Ruling 96-1
clarifies that the "orthotics" benefit is limited to leg, arm, back, and neck
braces that are used independently rather than in conjunction with, or as
components of, other medical or non-medical equipment.  
When consideration is made for a patient to require an orthotic, the therapist
targets the problems in performance of movements or tasks, or identifies a
part that requires immobilization, and selects the most appropriate orthotic
device, then fits the device, and trains the patient and/or caregivers in its
use and application. The goal is either to promote indicated immobilization or
to assist the patient to function at a higher level by decreasing functional
limitations or the risk of further functional limitations.  
The complexity of the patient's condition is to be documented to show the
medical necessity of skilled therapy to assess, fit, and instruct in the use
of the orthotic.  
An orthotic may be prefabricated or custom-fabricated.  
 _A prefabricated orthotic_ is one that is manufactured in quantity and then
modified with a specific patient in mind. A prefabricated orthotic may be
trimmed, bent, molded (with or without heat), or otherwise modified for use by
a specific patient (i.e., custom fitted). An orthotic that is assembled from
prefabricated components is considered prefabricated.  
 _A custom fabricated orthotic_ is one that is individually made for a
specific patient starting with basic materials including, but not limited to,
plastic, metal, leather, or cloth, from the patient's individualized
measurements.  
  
 _A molded-to-patient model orthotic_ is a particular type of custom
fabricated orthotic in which an impression of the specific body part is made
and the impression is then used to make a positive model. The orthotic is
molded from the patient-specific model.  
Outpatient hospital therapy departments, comprehensive outpatient
rehabilitation facilities (CORFs), outpatient rehabilitation facilities,
nursing homes (limited to patients covered under a Medicare Part B stay), and
home health agencies (limited to patients not under a HH plan of care) bill
the Part A MAC for the orthotic utilizing the relevant HCPCS Level II L code
and revenue code 274 on the claim form. These settings do not require a DME
supplier billing enrollment to bill and be reimbursed for the L codes.  
A physical or occupational therapist in private practice or a physician/NPP is
considered by Medicare to be a "supplier" and must bill the Durable Medical
Equipment Medicare Administrative Contractor (DME MAC) for orthotics. Any
supplier that issues orthotics must be enrolled as a supplier of Durable
Medical Equipment, Prosthetics, Orthotics, or Supplies (DMEPOS) prior to
billing the DME MAC. Follow the directions from the DME MAC when billing for
orthotics (utilizing an L code). Note: Therapists in private practice and
physicians/NPPs should follow the guidance below for billing to the Medicare
carrier/Part B MAC.  
 _Payment for prosthetics and orthotics is made on the basis of a fee schedule
whether it is billed to the DME MAC or the FI/Part A MAC._  
The L codes for orthotics provide a brief description of the device and
describe whether the device needs to be molded to a patient model, custom
fabricated, custom fitted, or have no fitting specifications. Select the
appropriate L code based on the description of the brace provided.  
The Medicare payment for the L codes includes the following items.

  * Assessment of the patient regarding the orthotic
  * Measurement and/or fitting
  * Supplies to fabricate or modify the orthotic
  * Time associated with making the orthotic

  
The appropriate CPT code should be used for orthotic "training" completed by
qualified professionals/auxiliary personnel. The code may be used in
conjunction with the L code only for the time spent training the patient in
the use of the orthotic. Orthotic training may include teaching the patient
regarding a wearing schedule, placing and removing the orthosis, skin care and
performing tasks while wearing the device. To avoid duplicate billing, the
time spent assessing, measuring and/or fitting, fabricating or modifying, or
making the orthotic may not be included in calculating the number of units to
bill when also billing the appropriate L code. The code for orthotic training
is a "timed" code and only minutes actually spent in the training of the
patient should be counted when determining units to bill when an L code is
also billed.  
There may be circumstances where a patient is only going to be seen for a
brief therapy episode for issuance of an orthotic. If it is not necessary to
complete a full, comprehensive patient evaluation, but only an assessment
related to determining the specific orthotic, do not bill an initial therapy
evaluation code in addition to the L code.  
For other patient situations however, a full patient initial evaluation is
needed to develop the appropriate treatment plan in addition to an assessment
related to determining the specific orthotic. In these situations, it may be
appropriate to bill the initial evaluation code with the minutes spent for the
evaluation assigned to the code. For example, a patient is referred to
occupational therapy for a wrist- hand orthotic with possible continued
therapy. The OT spends 35 minutes evaluating the patient which includes the
history, subjective complaints, prior and current functional levels, ROM,
strength, sensation, skin integrity, and ADL assessment. This time would be
assigned to the OT evaluation codes. The OT then begins the assessment of the
patient for the orthotic which includes determining the need for the orthotic
and the type of orthotic, subsequently fabricating the appropriate device and
fitting it to the patient. This time, which takes 45 minutes, would be
reimbursed under the L code. The OT spends an additional 20 minutes training
the patient in the wearing schedule of the orthotic, skin care and exercises
to be performed while the orthotic is in place.

Per CPT Assistant, February 2007, "Orthotic management code includes
additional orthotic management and training during follow-up visits including
exercises performed in the orthotic, instruction in skin care and orthotic
wearing time, and time associated with modification of the orthotic due to
healing of tissues, change in edema, or interruption in skin integrity."  
For an orthotic to be billed, it must be medically necessary for the patient's
condition. To bill for training the patient to use the orthotic  the
documentation must justify the need for a skilled qualified
professional/auxiliary personnel to train the patient in the use and care of
the orthotic. When the management of the orthotic can be turned over to the
patient, the caregiver or nursing staff, the services of the therapist will no
longer be covered.  
An orthotic provided for positioning and/or increasing range of motion in a
non-functional extremity must include documentation that the unique skills of
a therapist are required to fit and manage the orthotic and that the orthotic
is medically necessary for the patient's condition.  
For **uncomplicated** conditions, the following services would not be
considered reasonable and necessary as they would not require the unique
skills of a therapist.

  * Issuing off-the-shelf splints for foot drop or wrist drop
  * Issuing off-the-shelf foot or elbow cradles for routine pressure relief (these are not considered orthotics)
  * Issuing "carrots" (i.e., cylindrical, cone-shaped forms) or towel rolls for hand contractures for hygiene purposes
  * Bed positioning (e.g., pillows, wedges, rolls, foot cradles to relieve potential pressure areas)

  
Repetitive range of motion prior to placing an orthotic/positioner to maintain
the range of motion is not reasonable and necessary when the therapeutic
intent is primarily to maintain range of motion within a chronic condition.  
Ongoing therapy visits for increasing wearing time are generally not
reasonable and necessary when patient problems related to the orthotic have
not been observed.  
Ongoing visits by the qualified professional/auxiliary personnel to apply the
device would be considered monitoring. Once the initial fit is established,
any further visits should be used for specific documented problems and
modifications that require skilled therapy. It is reasonable and necessary to
require 1-3 visits to fit and educate the patient or caregiver. The medical
necessity of any further visits must be supported by documentation in the
medical record.  
Coverage is not for prefabricated/commercial (i.e., off the shelf) components
such as, but not limited to a lumbar roll, non-customized foam supports/wedges
(e.g., heel cushions), or multi-podus boots. Such components do not require
the skills of a therapist and are non-covered. Minor modifications to
prefabricated orthotics do not constitute a customized orthotic.  
It is not appropriate to bill for measurements taken to obtain custom fitted
burn or pressure garments. These garments do not fit the definition of an
orthotic.  
 **Supportive Documentation Recommendations for Orthotic management and
training**

  * A description of the patient's condition (including applicable impairments and functional limitations) that necessitates an orthotic
  * Any complicating factors
  * The specific orthotic provided and the date issued
  * A description of the skilled training provided
  * Response of the patient to the orthotic

  
  
**Prosthetic training**  
Prosthetic training includes preparation of the stump, skin care, modification
of prosthetic fit (revisions to socket liner or stump socks), and initial
mobility and functional activity training. Once a patient begins gait training
with the prosthesis, use code for therapeutic procedure; gait training.  
 **Supportive Documentation Recommendations for prosthetic training**

  * Type of prosthesis, extremity involved
  * Specific training provided and amount of assistance needed
  * Any complicating factors and specific description of these (with objective measurements), such as pain, joint restrictions/contractures, strength deficits, etc.

  
  
**C/o for orthotic/prosth use**  
  
These assessments are intended for established patients who have already
received their orthotic or prosthetic device.  
These assessments of the response to wearing the device may be reasonable and
necessary when patients experience a loss of function directly related to the
device (e.g., pain, skin breakdown, and falls). According to CPT Assistant -
February 2007, code for orthotic prosthetic includes patient's response to
wearing the device, whether the patient is donning/doffing the device
correctly, patient's need for padding, under wrap, or socks, and of the
patient's tolerance to any dynamic forces being applied.  
If the checkout assessment resulted in the need for further training in the
use of the orthotic/prosthetic, would be appropriate for the training.  
These assessments may not be considered reasonable and necessary when a device
is newly issued or when a device is reissued or replaced after normal wear and
no modifications are needed.  
Documentation must clearly support the need for more than 2 visits for the
checkout assessment.  
This is not covered on the same date as CPT codes an evaluation.  
 **Supportive Documentation Recommendations for orthotic/prosth use**

  * Reason for assessment
  * Findings from the assessment
  * Specific device, modifications made, instruction given

  
**Physical medicine procedure**  
If an existing CPT code does not describe the service performed, an unlisted
CPT code may be used. The use of unlisted codes should be rare. If unlisted
codes are billed, the claim and medical record must clearly state what
modality or procedure is billed as an unlisted code. If not, the unlisted code
billed will be subject to denial for insufficient information.  
 **Supportive Documentation Recommendations for physical medicine**  
Please see Documentation Requirements for Unlisted Procedure codes. This is an
untimed code, billable as "1" unit.  
Please see the Unlisted Procedure Codes section of article A46198, Outpatient
Physical and Occupational Therapy Services - Supplemental Instructions
Article, for specific billing instructions.  
  
 **Electrical stimulation, (unattended), to one or more areas, for chronic
stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and
venous stasis ulcers not demonstrating measurable signs of healing after 30
days of conventional care, as part of a therapy plan of care  
  
Electromagnetic therapy, to one or more areas for chronic stage III and stage
IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers
not demonstrating measurable signs of healing after 30 days of conventional
care as part of a therapy plan of care**  
  
  
 _  Nationally Covered Indications _(CMS Publication 100-03, _Medicare
National Coverage Determinations_ (NCD) Manual, section 270.1): _Electrical
stimulation (ES) and electromagnetic therapy for the treatment of wounds are
considered adjunctive therapies, and will only be covered for chronic Stage
III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous
stasis ulcers. Chronic ulcers are defined as ulcers that have not healed
within 30 days of occurrence. ES or electromagnetic therapy will be covered
only after appropriate standard wound therapy has been provided for at least
30 days and there are no measurable signs of healing. This 30-day period may
begin while the wound is acute.  
Standard wound care includes optimization of nutritional status, debridement
by any means to remove devitalized tissue, maintenance of a clean, moist bed
of granulation tissue with appropriate moist dressings, and necessary
treatment to resolve any infection that may be present. Standard wound care
based on the specific type of wound includes frequent repositioning of a
patient with pressure ulcers (usually every 2 hours), off-loading of pressure
and good glucose control for diabetic ulcers, establishment of adequate
circulation for arterial ulcers, and the use of a compression system for
patients with venous ulcers.  
Measurable signs of healing include a decrease in wound size (either surface
area or volume), decrease in amount of exudates, and decrease in amount of
necrotic tissue. ES or electromagnetic therapy must be discontinued when the
wound demonstrates a 100% epithelialized wound bed. _ES and electromagnetic
therapy services can only be covered when performed by a therapist, a
physician or incident to a physician's service.  
Evaluation of the wound is an integral part of wound therapy. When providing
ES or electromagnetic therapy, the therapist must evaluate and frequently
reassess the wound, contacting the treating physician if the wound worsens (do
not bill a re- evaluation code for the wound assessment). _If ES or
electromagnetic therapy is being used, wounds must be evaluated at least
monthly by the treating physician._  
Per NCD 270.1, electrical stimulation and electromagnetic therapy are NOT
COVERED for the treatment of:

  * stage I or stage II wounds;
  * electrical stimulation or electromagnetic therapy when used as an initial treatment modality;
  * continued treatment with ES or electromagnetic therapy if measurable signs of healing have not been demonstrated within any 30-day period of treatment;
  * wounds that demonstrate a 100% epithelialized wound bed;
  * a patient in the home setting, as unsupervised use by patients in the home has not been found to be medically reasonable and necessary.

  
**Supportive Documentation Recommendations for Electrical stimulation,
(unattended) and G0329**

  * Etiology and duration of wound
  * Type of prior treatments by a physician, non-physician practitioner, nurse and/or therapist that failed, including the duration of the failed treatment
  * Stage of wound
  * Description of wound: length, width, depth, grid drawing and/or photographs Amount, frequency, color, odor, type of exudate
  * Evidence of infection, undermining, or tunneling Nutritional status
  * Comorbidities (e.g., diabetes mellitus, peripheral vascular disease) Pressure support surfaces in use
  * Patient's functional level
  * Skilled plan of treatment, including specific frequency of the modality
  * Changing plan of treatment based on clinical judgment of the patient's response or lack of response to treatment
  * Frequent skilled observation and assessment of wound healing (at least weekly, but preferably with each treatment session)

  
  
**Electrical stimulation, (unattended), to one or more areas, for wound care
other than described from above**  
This code is not covered by Medicare.  
 ** _Other Available Therapy Codes_**  
  
 **Muscle and Range of Motion Testing**  
For the typical patient, the evaluation  and reevaluation codes  include all
the necessary evaluation tools, including range of motion and manual muscle
testing. Baseline measurements may be done with an initial evaluation, but are
not separately billable in addition to the evaluation. In addition,
assessments, which are separate from evaluations and reevaluations, are
included in the therapy treatment services and procedures and should be coded
consistent with the intervention for which the assessment is necessary.  
Assessments must be provided by therapists or physician/NPP (not therapy
assistants) and include objective testing and measurement (such as ROM and
manual muscle testing) to make clinical judgments regarding the patient's
condition to determine the next step in the treatment plan.  
  
On rare occasions, it may be appropriate to perform a thorough range of motion
or manual muscle test during the course of treatment that is separate from the
evaluation/reevaluation. Patients with complicated conditions may warrant
specialized tests and measures with standardized reports. For example, a
patient with an incomplete C5 quadriplegia at six months post-injury may need
specialized testing for ROM or strength measurements to address specific
deficits and goals.  
Testing must be pertinent to the plan of care and the diagnosis.  
Every muscle or joint in the affected extremity or trunk section, as described
in the code descriptor, must be tested when coding these procedures. For
example:

  * "Muscle testing, manual with report: extremity (excluding hand) or trunk". To use this code for extremity manual muscle testing, every muscle of at least one extremity would need to be tested, with documentation of why such a thorough assessment was warranted. It would not be appropriate to bill the code if only hip strength needed to be tested.
  * "Range of motion measurements and report; each extremity (excluding hand) or trunk section (spine)". To use this code for extremity ROM testing, every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted. It would not be appropriate to bill the code if only shoulder ROM needed to be tested.

  
It is not reasonable or necessary for these codes to be performed on a routine
basis or to be routinely used for all patients (e.g., monthly or in the place
of billing for a reevaluation).  
  
  
 **Supportive Documentation Recommendations**  
These codes are typically consultative. It is expected that the administration
of these tests will generate material that will be formulated into a report.
That report should clearly indicate the purpose and rationale for the test,
the test performed with results and how the information affects the treatment
plan.  
 **Application of Casts and Strapping Codes**  
The casting and strapping procedures apply when the cast application or
strapping is a replacement procedure used during or after the period of
follow-up care, or when the cast application or strapping is an initial
service performed without a restorative treatment or procedure(s) to stabilize
or protect a fracture, injury, or dislocation and/or to afford comfort to a
patient.  
  
A physician who applies the initial cast, strap or splint and also assumes all
of the subsequent fracture, dislocation, or injury care cannot use the
application of casts and strapping codes as an initial service, since the
first cast/splint or strap application is included in the treatment of
fracture and/or dislocation codes. A temporary cast/splint/strap is not
considered to be part of the preoperative care.  
  
 **General Guidelines for Casting**  
Therapists typically do not utilize casting interventions for the treatment of
fractures. However, casting techniques used by therapists for positioning and
stretching are a covered service when an improvement can be noted in an
individual's movement patterns and skills. For example, a spastic hand can be
casted to facilitate relaxation of the fingers. Serial casting can be
essential for individuals with traumatic brain injury- induced spasticity,
CVA, and other conditions. Casting should not be utilized for basic
contracture management issues. Casting goals should objectively indicate
expectation of progress, whereas, the main function of contracture management
is to decrease the risk of further contracture.  
More than 8-10 visits for evaluation, treatment, modification and caregiver
education would not be considered reasonable and necessary without significant
documentation.  
These are untimed codes.  
 **General Guidelines for Strapping  
**  
  
Strapping refers to the application of overlapping strips of adhesive plaster
or tape to a body part to exert pressure and hold a structure in place.
Strapping may be used to treat strains, sprains, dislocations, and some
fractures. The strapping codes are intended to be used when the desired effect
is to provide total immobilization or restriction of movement. These services
are typically performed outside a therapy plan of care.  
Strapping is not always synonymous with taping (such as McConnell taping or
kinesiotaping). See additional information on taping under therapeutic
procedures. See the code for wrapping techniques for manual lymphatic
drainage.  
For dates of service on and after 10/1/2010, low back strapping (regardless of
CPT code billed) will be considered a non-reimbursable service under Medicare,
as the service has been removed from CPT as an obsolete procedure [CPT Changes
2010 - An Insider's View, page 91].  
 _Special instructions for - Strapping; Unna boot_  
The application of Unna boot paste (zinc, gelatin, or other product) as a
bandage or "colloid" dressing, is applied to an extremity for the treatment of
dermatological, vascular, and on occasion, other conditions. These dressings
are often covered by an elastic bandage to give added support, hold the
dressing in place and provide a protective cover. Unna boot application is
appropriate in the treatment of ulcerations with and without inflammation due
to stasis dermatitis produced by vascular insufficiency. The Unna boot is also
appropriate for treating ligamentous injuries (sprains and strains) of the
ankle. Unna boots need to be changed on a regular basis, depending on the
exact type used and the indication. Bilateral unna boots should be billed with
a modifier -50 (bilateral procedure).  
These are untimed codes.  
 **Unlisted procedure, casting or strapping**  
If an existing CPT code does not describe the service performed, an unlisted
CPT code may be used. The use of unlisted codes should be rare. If unlisted
codes are billed, the medical record and claim must clearly state what
modality or procedure is billed as an unlisted code. If not, the unlisted code
billed will be subject to denial for insufficient information. As of
10/01/2010, low back strapping  should not be billed with unlisted procedure,
casting or strapping.  
  
 _Supportive Documentation Recommendations unlisted procedure, casting or
strapping_  
This is an untimed code, billable as "1" unit.  
Please see section Documentation Recommendations for Unlisted Procedure Codes.  
Please see the Unlisted Procedure Codes section of article A49932, Outpatient
Physical and Occupational Therapy Services - Supplemental Instructions
Article, for specific billing instructions.  
 **General Guidelines for Splinting**  
According to CPT Assistant-February 2007, orthosis application differs from
the purpose of an application of a cast or strapping device. Casting and
strapping codes should not be reported for orthotics fitting and training.  
Splinting codes, though rarely used by therapists, may be appropriate for
clinical situations (e.g., fracture, sprain, dislocation) where temporary
immobilization/fixation is required until there is further treatment
disposition.  
This example is based upon a clinical vignette in CPT Assistant-April 2002.
Patient C is a 70-year-old female who presents to the outpatient orthopedic
clinic following a left ankle injury when her foot became twisted in her dog's
run chain. After the orthopedist evaluates the patient, radiologic views were
obtained that substantiated the diagnosis of a sprained ankle ligament. A
short-leg plaster posterior molded splint is applied by the physical therapist
due to the degree of swelling. Upon return to the orthopedic clinic, the
splint is removed, x-rays repeated, and based on those findings, a short-leg
fiberglass non-walking cast is applied.  
These are untimed codes.  
  
 **  Biofeedback training by any modality  
 Biofeedback training, perineal muscles, anorectal or urethral sphincter,
including EMG and/or manometry**  
Biofeedback therapy provides visual, auditory or other evidence of the status
of certain body functions so that a person can exert voluntary control over
the functions, and thereby alleviate an abnormal bodily condition. Biofeedback
therapy often uses electrical devices to transform bodily signals indicative
of such functions as heart rate, blood pressure, skin temperature, salivation,
peripheral vasomotor activity, and gross muscle tone into a tone or light, the
loudness or brightness of which shows the extent of activity in the function
being measured.  
 _Biofeedback therapy differs from electromyography which is a diagnostic
procedure used to record and study the electrical properties of skeletal
muscle. An electromyography device may be used to provide feedback with
certain types of biofeedback.  
Biofeedback therapy is covered under Medicare only when it is reasonable and
necessary for the individual patient for muscle re-education of specific
muscle groups or for treating pathological muscle abnormalities of spasticity,
incapacitating muscle spasm, or weakness, and more conventional treatments
(heat, cold, massage, exercise, support) have not been successful. This
therapy is not covered for treatment of ordinary muscle tension states or for
psychosomatic conditions_. (CMS Publication 100-03, _Medicare National
Coverage Determinations_ (NCD) Manual, Section 30.1)  
 _Biofeedback for incontinence_  
 _Biofeedback is covered for the treatment of stress and/or urge incontinence
in cognitively intact patients who have failed a documented trial of pelvic
muscle exercise (PME) training. Biofeedback is not a treatment, per se, but a
tool to help patients learn how to perform PME. Biofeedback-assisted PME
incorporates the use of an electronic or mechanical device to relay visual
and/or auditory evidence of pelvic floor muscle tone, in order to improve
awareness of pelvic floor musculature and to assist patients in the
performance of PME.  
A failed trial of PME training is defined as no clinically significant
improvement in urinary incontinence after completing four weeks of an ordered
plan of pelvic muscle exercises to increase periurethral muscle strength._  
  
Medicare will allow biofeedback as an initial incontinence treatment modality
only when, in the opinion of the physician, that approach is most appropriate
and there is documentation of medical justification and rationale for why a
PME trial was not attempted first.  
  
Patient selection is a major part of the process and the patient should be
motivated, cognitively intact, and compliant. In addition, there must be
assurance that the pelvic floor musculature is intact. Biofeedback therapy has
proven successful for urinary incontinence when all three of the following
conditions exist:

  * the patient is capable of participation in the plan of care;
  * the patient is motivated to actively participate in the plan of care, including being responsive to the care requirements (e.g., practice and follow-through by self or caregiver); and
  * the patient's condition is appropriately treated with biofeedback (e.g., pathology does not exist preventing success of treatment).

  
When providing biofeedback procedures for urinary incontinence, use the
appropriate CPT code when EMG and/or manometry are not performed.  
Biofeedback that is more involved than conventional biofeedback measures  and
includes evaluations of the EMG activity of the pelvic muscles, urinary
sphincter and/or anal sphincter by using sensors. This procedure can use
manometry (measure of pressure of gases or liquids by use of a manometer) or
EMG (electromyography - the recording of electrical activity initiated in the
muscle tissue for testing purposes) to measure activity. The EMG activity is
evaluated and provides objective information regarding the muscle activity and
provides a basis for pelvic muscle rehabilitation utilizing biofeedback.  
Biofeedback is non-covered for:

  * home use of biofeedback therapy;
  * pelvic floor electrical stimulation lacking documentation of the failure of a trial of pelvic muscle exercise (PME) training, unless there is physician documentation justifying the need to initiate treatment with biofeedback before PME is attempted;
  * patients who do not have sufficient cognitive ability to adhere to and follow the PME protocol and/or cooperate in keeping a personal voiding diary.

  
Patients not showing improvement after 5-6 visits of retraining with
biofeedback are not likely to improve with additional sessions. Additional
documentation is necessary to justify biofeedback services beyond 5-6 visits.  
The descriptor for the biofeedback codes does not include a time element;
therefore, these codes should be billed as one (1) unit.  
  
 **Supportive Documentation Recommendations for biofeedback**  
As noted in the NCD descriptions above, biofeedback is covered only when more
conventional treatments such as heat, cold, massage, exercise (such as PME),
and/or support have not been successful. Therefore, documentation must provide
a clear history of the conventional treatments unsuccessfully tried before
initiating biofeedback. Since biofeedback is only covered when there is a lack
of response to other therapies, the lack of response to or contraindication
to, other therapies must be noted in the patient's record.  
 _Additionally for the treatment of incontinence, include:_

  * identification of the type and degree of incontinence, expectations from the treatment and the time frame in which an improvement is anticipated;
  * clear documentation of the formal instruction, monitoring and follow-up of a prescribed course of PME;
  * evidence of behavioral modification training including, but not limited to, bladder retraining and fluid intake modification;
  * the use of a patient record-keeping system, such as a personal voiding diary, in evaluating and monitoring progress.

  
**Standardized cognitive performance testing (e.g., Ross Information
Processing Assessment) per hour of a qualified health care professional 's
time, both face-to-face time administering tests to the patient and time
interpreting these test results and preparing the report.  
**  
  
According to CPT 2008 Changes, An Insider's View, patients who have
compromised functioning abilities due to acute neurological events such as TBI
or CVA must undergo assessment to determine if abilities such as orientation,
memory and high-level language function have been comprised and to what
extent. Health care professionals such as speech-language pathologists (SLPs)
and OTs perform a battery of test procedures called standardized cognitive
performance testing in order to make these important determinations. These
tests evaluate different aspects of neurocognitive function including memory
(short-term, long-term, and organizational), reasoning, sensory processing,
visual perceptual status, orientation, right hemisphere processing for
temporal and spatial organization, social pragmatics, and elements of
decision- making and executive function.  
  
A code has been established to report these test procedures when performed by
qualified health care professionals, such as SLPs and OTs. This is a time-
based code intended to be reported per hour, including the time administering
the tests to the patient, interpreting the results, and preparing the report.
Note that this code includes both face-to-face time and non-face-to-face time.  
  
  
Clinical example:  
A 36 year old male with Traumatic Brain Injury from a motor vehicle accident
is referred to the health care professional for standardized cognitive
performance testing following a recent discharge. The qualified health care
professional selects and completes face-to- face administration of the
appropriate standardized test(s) to examine the patient's current level of
functional cognitive performance. Raw and standardized scores are derived and
analyzed. A written report is prepared by the qualified health care
professional and sent to the referring physician.  
 **Miscellaneous Services (Non-covered)**  
The following are non-covered as skilled therapy services. This is not an all
inclusive list.

    * Iontophoresis, except as indicated for primary focal hyperhidrosis
    * Anodyne
    * Low level laser treatment (LLLT)/cold laser therapy
    * Dry hydrotherapy massage (e.g., aquamassage, hydromassage, or water massage)
    * Massage chairs or roller beds
    * Interactive metronome therapy
    * Loop reflex training
    * Vestibular ocular reflex training
    * Continuous passive motion (CPM) device setup and adjustments
    * Craniosacral therapy
    * Electro-magnetic therapy, except as indicated for chronic wounds
    * Constraint Induced Movement Therapy (CIMT)
    * Driving assessments
    * Work-hardening programs
    * Pelvic Floor Dysfunction (not including incontinence)  

      * Due to the lack of peer reviewed evidence concerning the effect on patient health outcomes, skilled therapy interventions (e.g., ultrasound, electrical stimulation, soft tissue mobilization, and therapeutic exercise) for the treatment of the following conditions is considered investigational and thus non-covered.  

        * pelvic floor congestion
        * pelvic floor pain not of spinal origin
        * hypersensitive clitoris
        * prostatitis
        * cystourethrocele
        * enterocele
        * rectocele
        * vulvodynia
        * vulvar vestibulitis syndrome (VVS)



  * Functional Electrical Stimulating (FES) devices other than those that assist in walking are not covered under Medicare [NCD 160.12]. Consequently, any services related to the evaluation for or training of patients to use such a device is not covered. Such devices may include, but are not limited, to the Ergys system.