Outpatient occupational and physical therapy services are those services provided within the scope of practice of physical therapists and occupational therapists and necessary for the diagnosis and treatment of impairments, functional limitations, disabilities or changes in physical function and health status.

The concept of rehabilitative therapy includes recovery or improvement in function and, when possible, restoration to a previous level of health and well-being.

In addition to general guidelines addressing therapy services, specific information is included addressing the following NCDs:

• NCD 150.5 Diathermy Treatment
• NCD 150.8 Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorder
• NCD 160.15 Electrotherapy for Treatment of Facial Nerve Paralysis (Bell’s Palsy)
• NCD 270.6 Infrared Therapy Devices

For information on Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds – NCD 270.1, see Medical Policy N-14.

For information on Infrared Therapy Devices, see Medical Policy E-43.

Outpatient physical and occupation therapy services are covered benefits.  In order for therapy services to be covered, they must be reasonable and necessary.  Services that do not meet the medical necessity guidelines outlined in this policy will be considered “not medically necessary”.  Effective January 26, 2009, a provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Outpatient therapy services furnished to a member by a provider are payable only when furnished in accordance with certain conditions. The following conditions of coverage apply:

• Services are or were required because the individual needed therapy services; and, 
• A plan for furnishing such services has been established by a physician/NPP or by the therapist providing such services and is periodically reviewed by a physician/NPP; and ,
• Such services are or were furnished while the individual is or was under the care of a physician; and,
• Services must be furnished on an outpatient basis.

All of the conditions are met when a physician/NPP certifies an outpatient plan of care for therapy. Certification is required for coverage and payment of a therapy claim.

To be considered reasonable and necessary, the following conditions must each be met:

• The services shall be considered under accepted standards of medical practice to be a specific and effective treatment for the patient’s condition.
  
• 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 be safely and effectively performed only by a therapist. Services that do not require the performance or supervision of a therapist are not skilled and are not considered reasonable or necessary therapy services, even if they are performed by a qualified professional.
  
• There must be an expectation that the patient’s condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state. In the case of a progressive degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function.
  
• The amount, frequency, and duration of the services must be reasonable under accepted standards of practice.

Maintenance Program

During the last visits for rehabilitative treatment, the clinician may develop a maintenance program. The goals of a maintenance program would be, for example, to maintain functional status or to prevent decline in function. The specialized skill, knowledge and judgment of a therapist would be required, and services are covered, to design or establish the plan, assure patient safety, train the patient, family members and/or unskilled personnel and make infrequent but periodic reevaluations of the plan.

The services of a qualified professional are not necessary to carry out a maintenance program, and are not covered under ordinary circumstances. The patient may perform such a program independently or with the assistance of unskilled personnel or family members.

Example: A Parkinson patient who has been under a rehabilitative physical therapy program may require the services of a therapist during the last week or two of treatment to determine what type of exercises will contribute the most to maintain the patient’s present functional level following cessation of treatment.  In such situations, the design of a maintenance program appropriate to the capacity and tolerance of the patient by the qualified therapist, the instruction of the patient or family members in carrying out the program, and such infrequent reevaluations as may be required would constitute covered therapy because of the need for the skills of a qualified professional.

Physical Therapy and Occupational Therapy Plan of Care

Outpatient therapy must be under the care of a physician/non-physician practitioner (NPP). An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician.

The services must relate directly and specifically to a written treatment plan. The plan, (also known as a plan of care or plan of treatment) must be established before treatment is begun. The plan is established when it is developed (e.g., written or dictated).

The signature and professional identity (e.g., MD,) of the person who established the plan, and the date it was established must be recorded with the plan. Establishing the plan, which is described below, is not the same as certifying the plan.

Outpatient therapy services shall be furnished under a plan established by: 

• A physician/NPP (consultation with the treating physical or occupation therapist recommended); or,
  
  
• The physical therapist or occupational therapist that will provide the therapy services.

The plan may be entered into the patient’s therapy record either by the person who established the plan or by the provider’s or supplier’s staff when they make a written record of that person’s oral orders before treatment is begun.

The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits. It is appropriate that treatment begins when a plan is established.

Therapy may be initiated by qualified professionals or qualified personnel based on a dictated plan. Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who establishes the plan. Payment for services provided before a plan is established may be denied.

The plan of care shall contain, at minimum, the following information: 

• Diagnoses;
• Long term treatment goals; and,
• Type, amount, duration and frequency of therapy services.

Changes are made in writing in the patient’s record and signed by one of the following professionals responsible for the patient’s care: 

• The physician/NPP;
• The physical therapist (in the case of physical therapy);
• The occupational therapist (in the case of occupational therapy); or,
• The registered professional nurse or physician/NPP on the staff of the facility pursuant to the oral orders of the physician/NPP or therapist.

While the physician/NPP may change a plan of treatment established by the therapist providing such services, the therapist may not significantly alter a plan of treatment established or certified by a physician/NPP without their documented written or verbal approval. A change in long-term goals, (for example if a new condition was to be treated) would be a significant change. Physician/NPP certification of the significantly modified plan of care shall be obtained within 30 days of the initial therapy treatment under the revised plan. An insignificant alteration in the plan would be a change in the frequency or duration due to the patient’s illness, or a modification of short-term goals to adjust for improvements made toward the same long-term goals. If a patient has achieved a goal and/or has had no response to a treatment that is part of the plan, the therapist may delete a specific intervention from the plan of care prior to physician/ NPP approval. This shall be reported to the physician/NPP responsible for the patient’s treatment prior to the next certification.

Procedures (e.g., neuromuscular reeducation) and modalities (e.g., ultrasound) are not goals, but are the means by which long and short term goals are obtained.  Changes to procedures and modalities do not require physician signature when they represent adjustments to the plan that result from a normal progression in the patient’s disease or condition or adjustments to the plan due to lack of expected response to the planned intervention, when the goals remain unchanged.  Only when the patient’s condition changes significantly, making revision of long term goals necessary, is a physician’s/NPP’s signature required on the change, (long term goal changes may be accompanied by changes to procedures and modalities).

Certification and Recertification

Certification is required for coverage and payment of a therapy claim.  It is not required that the same physician/NPP who participated initially in recommending or planning the patient’s care certify or recertify the plans.

The physician’s/NPP’s certification of the plan (with or without an order) satisfies all of the certification requirements for the duration of the plan of care, or 90 calendar days from the date of the initial treatment, whichever is less. The initial treatment includes the evaluation that resulted in the plan.

Timing of Initial Certification:  The provider or supplier (e.g., facility, physician/NPP, or therapist) should obtain certification as soon as possible after the plan of care is established, unless the requirements of delayed certification are met. “As soon as possible” means that the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment

Recertification:  Recertifications that document the need for continued or modified therapy should be signed whenever the need for a significant modification of the plan becomes evident, or at least every 90 days after initiation of treatment under that plan, unless they are delayed

Physicians/NPPs may require that the patient make a physician/NPP visit for an examination if, in the professional’s judgment, the visit is needed prior to certifying the plan, or during the planned treatment. Physicians/NPPs should indicate their requirement for visits, preferably on an order preceding the treatment, or on the plan of care that is certified.

If the physician wishes to restrict the patient’s treatment beyond a certain date when a visit is required, the physician should certify a plan only until the date of the visit. After that date, services will not be considered reasonable and necessary due to lack of a certified plan. Physicians/NPPs should not sign a certification if they require a visit and a visit was not made.

Delayed Certification:  Certifications are required for each interval of treatment based on the patient’s needs, not to exceed 90 calendar days from the initial therapy treatment. Certifications are timely when the initial certification (or certification of a significantly modified plan of care) is dated within 30 calendar days of the initial treatment under that plan. Recertification is timely when dated during the duration of the initial plan of care or within 90 calendar days of the initial treatment under that plan, whichever is less. Delayed certification and recertification requirements shall be deemed satisfied where, at any later date, a physician/NPP makes a certification accompanied by a reason for the delay. Certifications are acceptable without justification for 30 days after they are due. Delayed certification should include one or more certifications or recertifications on a single signed and dated document

It is not intended that needed therapy be stopped or denied when certification is delayed. The delayed certification of otherwise covered services should be accepted unless there is reason to believe that there was no physician involved in the patient’s care, or treatment did not meet the patient’s need (and therefore, the certification was signed inappropriately).

Therapy Assistants
The services of PTAs or OTAs used when providing covered therapy benefits are included as part of the covered service.  These services are billed by the supervising physical or occupational therapist.  Therapy assistants may not provide evaluation services, make clinical judgments or decisions or take responsibility for the service.  They act at the direction and under the supervision of the treatment therapist.

Untimed Codes
When reporting service units for codes where the procedure is not defined by a specific timeframe (untimed codes), the units reported are based on the number of times the procedure is performed, as described in the code definition (often once per day).  However, there may be two treatment sessions per day, for example, in the morning and afternoon.  When there are two visits/treatments sessions in a day, plans of care indicate treatment amount of twice a day.

Timed Codes
Several codes used for therapy modalities, procedures, and tests and measurements specify that the direct (one-on-one) time spent in patient contact is 15 minutes.  Providers report procedure codes for services delivered on any single calendar day using CPT codes and the appropriate number of 15 minute units of service.

Providers report the code for the time actually spent in the delivery of the modality requiring constant attendance and therapy services. Pre- and post-delivery services are not to be counted in determining the treatment service time. In other words, the time counted as “intra-service care” begins when the therapist or physician (or an assistant under the supervision of a physician or therapist) is directly working with the patient to deliver treatment services. The patient should already be in the treatment area (e.g., on the treatment table or mat or in the gym) and prepared to begin treatment.

When only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed code in the same day measured in 15 minute units, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be billed.

Time intervals for 1 through 8 units are as follows:

The pattern remains the same for treatment times in excess of 2 hours.

When more than one service represented by 15 minute timed codes is performed in a single day, the total number of minutes of service (as noted on the chart above) determines the number of units billed.

If any 15 minute timed service that is performed for 7 minutes or less than 7 minutes on the same day as another 15 minute timed service that was also performed for 7 minutes or less and the total time of the two is 8 minutes or greater than 8 minutes, then bill one unit for the service performed for the most minutes. This is correct because the total time is greater than the minimum time for one unit. The same logic is applied when three or more different services are provided for 7 minutes or less than 7 minutes.

CMS National Coverage Decisions

• Diathermy Treatment (Code 97024) - (NCD 150.5)
  Where the contractor's medical staff determines that a pulsed wave diathermy apparatus used is one that is considered therapeutically effective, the treatments are considered a covered service, but only for those conditions for which standard diathermy is medically indicated and only when rendered by a physician or incident to a physician's professional services.
  
  
• Fluidized Therapy Dry heat for Certain Musculoskeletal Disorders (Code 97022) – (NCD 150.8)
  Fluidized therapy is a high intensity heat modality consisting of a dry 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 subacute traumatic or nontraumatic musculoskeletal disorders of the extremities.
  
  
• Electrotherapy for Treatment of Facial Nerve Paralysis (Bell’s Palsy) (Codes 97014, 97032, or G0283) – (NCD 160.15)
  Electrotherapy for the treatment of facial nerve paralysis, commonly known as Bell’s Palsy (diagnosis code 351.0), is not covered because its clinical effectiveness has not been established.  When reported for Bell’s Palsy, electrical stimulation therapy will be denied as not medically necessary.
  
  
• Infrared Therapy (Code 97026) – (NCD 270.6)
  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.
  
  When the application of infrared light, code 97026, is reported for these indications, the service will be denied as not medically necessary. 

Reasons for Noncoverage

• Services which do not meet the requirements for covered therapy services are not payable using codes and descriptions for therapy services.  For example, services related to activities for the general good and welfare of patients, e.g., general exercises to promote overall fitness and flexibility and activities to provide diversion or general motivation, do not constitute therapy services. 
  
  
• Services not provided under a therapy plan of care are not covered.
  
  
• Services that are provided by aids, even under the supervision of a therapist, are not therapy service, and are not covered therapy services.
  
  
• If an individual’s expected rehabilitation potential would be insignificant in relation to the extent and duration therapy services required to achieve such potential, therapy would not be covered because it is not considered rehabilitation or 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 of function (e.g., temporary weakness which may follow a brief period of bedrest following abdominal surgery) which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities.
  
  
• The services of a qualified professional are not necessary to carry out a maintenance program.  Services provided for maintenance purposes, S8990, are not covered.  A provider can bill the member for the denied service.
  
  
• The cost of supplies (99070), e.g., theraband, hand putty, electrodes, used in furnishing covered therapy care is included in the payment for the service billed by the physical therapist, and are therefore, not separately billable.  A provider cannot bill the member for the denied service.  NOTE:  This does not apply to splints and casts.
  
  
• The application of hot/cold packs, 97010, is considered a bundled service.  Separate payment is not allowed for this service.  A provider cannot bill the member for the denied service.
  
  
• The removal of devitalized tissue from wounds, non-selective debridement, without anesthesia (e.g., wet-to-dry moist dressings, enzymatic, abrasion) including topical application(s), wound assessment and instructions for ongoing care, code 97602, is considered a bundled service. Separate payment is not allowed for this service.  A provider cannot bill the member for the denied service.
  
  
• Work hardening services (97545, 97546) relate solely to specific work skills. They are considered not medically necessary for the diagnosis or treatment of illness or injury. These services relate solely to specific work skills.

Documentation Requirements

Required documentation includes: 

• Evaluation/and Plan of Care (may be one or two documents)
• Certification (physician/NPP approval of the Plan) and Recertification, if due
• Progress reports
• Treatment notes for each treatment day (may also serve as Progress Reports when required information is included in the notes)

Medical record documentation should justify the following:

• The patient was under the care of a physician/NPP
• Services required the skills of a therapist.
• Services are of appropriate type, frequency, intensity and duration for the individual needs of the patient

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

• Use code S8990 to report maintenance therapy.
• Code 97760 should not be reported with code 97116 for the same extremity.

Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-Line Manual 100-02, Chapter 5, Sections 20, 20.2, 20.3, 20.5

CMS On-Line Manual 100-02, Chapter 15, Sections 220 and 230

CMS On-Line Manual 100.03, Sections 150.5, 150.8, 160.15, 270.6

CMS On-Line Manual 100.04, Chapter 5, Section 20.4

Procedure codes 97014, 97032 or G0283 will be denied as not medically necessary with reported with the following diagnosis code:

Procedure code 97026 will be denied as not medically necessary when reported with the following diagnosis codes: