Physical medicine is a covered service when performed with the expectation of restoring the patient's level of function that has been lost or reduced by injury or illness.

This type of therapy should be provided in accordance with an ongoing, written treatment plan. The treatment plan should include:  

• the specific modalities/procedures to be used in treatment;
• the patient's diagnosis;
• degree of severity of the problem (mild, moderate, severe);
• impairment characteristics;
• physical examination findings - X-ray or other pertinent findings;
• specific statements of long- and short-term goals;
• a reasonable estimate of when the goals will be reached (estimated duration of treatment, e.g., number of weeks);
• the frequency of treatment (e.g., number of times per week); and,
• equipment and/or techniques utilized.

The treatment plan should be updated as the patient's condition changes.  Treatment plans for physical medicine, aquatic therapy, and gait training must be maintained in the medical record, and made available upon request.

A typical session usually consists of up to one hour of rehabilitative therapy or up to three physical medicine modalities/procedures performed on the same date of service.

Coverage for physical medicine is determined according to individual or group customer benefits.  Participating, preferred and network providers can bill the member for denied services that exceed the member's benefit limitations.

Outpatient physical medicine should be paid in accordance with the following guidelines:

Physical Medicine or Athletic Training Evaluation

An evaluation and management (E&M) service is considered an inherent part of a physical medicine evaluation (97001-97002) or athletic training evaluation (97005-97006).  The E&M service is not eligible for separate payment when reported on the same day as a physical medicine evaluation or athletic training evaluation.

Consequently, when an evaluation and management service is reported in conjunction with a physical medicine evaluation or athletic training evaluation, the services should be combined under the appropriate code for the physical medicine evaluation or athletic training evaluation. A participating, preferred, or network provider cannot bill the member for the E&M service. Modifier 25 may be reported with medical care (e.g. visits, consults) to identify it as significant and separately identifiable from the other service(s) provided on the same day. When modifier 25 is reported, the patient’s records must clearly document that separately identifiable medical care was rendered.

Muscle testing (95831-95834), range of motion testing (95851-95852), and physical performance testing (97750) are considered components of a physical medicine evaluation (97001-97002) or an athletic training evaluation (97005-97006), and are not eligible for separate payment when billed on the same day as a physical medicine evaluation or athletic training service.  Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Maintenance Therapy

Physical medicine performed repetitively to maintain a level of function is not eligible for payment. A participating, preferred, or network provider can bill the member for the denied service. A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Maintenance therapy should be reported under procedure code S8990.

Physical Medicine Modalities

Physical medicine modalities vary according to whether direct (one-on-one) or supervised contact is required for the treatment.

• Supervised Modalities Supervised modalities (codes 97010-97028) do not require direct one-on-one patient contact.  These are not time-based codes.  Therefore, it is not appropriate to report multiple units of services with codes 97010-97028. Report these codes only once during a patient encounter (visit), regardless of the amount of time spent supervising the modality or the number of body areas treated.
  
  
  Hot/Cold Packs: Code 97010 should be reported only one time for the use of both cold and hot packs during the same session.

Vasopneumatic Compression (97016)

Intermittent compression therapy is used to reduce edema and lymphedema of the extremities. This treatment is warranted for the following conditions:

• Edema of the extremities
• Hematoma of the leg
• Lymphedema of the arm
• Lymphedema of the leg
• Venous insufficiency or venous stasis disorder

Conditions other than those listed above or those which indicate that an infection is present should be denied as not medically necessary. Effective January 26, 2009, a participating, preferred or network 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 should be maintained in the provider's records.

Documentation to support the application of a compression device should include the type, amount and location of the edema as well as the circumferential measurements of the treated extremity, before and after treatment.

This service is considered a “supervised” modality and is not considered “time-based”.  It should be reported only once per treatment session, regardless of the number of areas treated or the length of time required to complete treatment.

Services provided by devices that provide both vasopneumatic compression and cold therapy simultaneously, should be reported with code 97016.  It is not appropriate to report cold therapy (97010) with vasopneumatic compression (97016) when services are provided simultaneously with the same device.

Infrared Therapy (97026)
The use of infrared and near-infrared light and heat, including monochromatic infrared energy, is not considered medically necessary when used as a physical medicine modality for the treatment of diabetic and/or non-diabetic peripheral sensory neuropathy and wounds and/or ulcers of the skin and/or subcutaneous tissues.

Infrared therapy, code 97026, will be denied as not medically necessary when reported for diagnosis codes listed in the Diagnosis Code Section of this policy.

A participating, preferred or network 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 should be maintained in the provider's records.

• Constant Attendance Modalities
  Constant attendance modalities (codes 97032-97039) are those modalities that require direct one-on-one patient contact by the provider.  These are time-based codes that include the time required to perform all aspects of the service, including pre,- intra-, and post-service work.  Documentation must include the amount of time spent in providing all aspects of this service.
  
  When two constant attendance modalities are performed at the same time, using one device, the code representing the primary modality should be reported.  For instance, when electrical stimulation and ultrasound are performed together using a device such as the Sonicator, report the ultrasound code.  It is not appropriate to report both modalities for the same 15-minute period of time.
  

Aquatic Therapy

Procedure code 97113 should be used to report aquatic therapy with therapeutic exercises. Aquatic therapy must be performed with the expectation of restoring a patient's level of function that has been lost or reduced by injury or illness. Aquatic therapy performed to maintain a level of function is considered to be a maintenance program. It is not eligible for payment.

A provider must have direct (one to one) patient contact when reporting aquatic therapy. Supervising multiple patients in a pool at one time and billing for each of these patients per 15 minutes of therapy time is not acceptable.

Before beginning an aquatic therapy program, the provider must prepare a treatment plan that includes short-term and long-term goals that the patient can be reasonably expected to accomplish through the aquatic therapy program and the specific methods chosen.  

Proper documentation should include:

• Documentation indicating whether the patient was in shallow or deep water. An aquatic therapy program undertaken for upper extremity exercises should take place in a depth of water that allows the patient's upper extremities to be submerged. Water depth should be at a level that provides the best postural position for exercise therapy.
• For resistance and strengthening exercises, the provider should document the number of repetitions, the number of sets, the type(s) of equipment, which body area(s) and the specific type(s) of exercise performed by the patient for each therapy session.

NOTE:

If a provider cannot substantiate increased resistance experienced as the patient

exercises in water, the session will be considered as endurance or conditioning
rather than progressive resistance exercises (PRE) to strengthen.

• Specific documented goals regarding decreasing inflammation, decreasing pain, increasing circulation, increasing strength, etc., and the means by which the specific goals will be achieved.
• Periodic re-evaluation documenting the number of times the patient has had rehabilitative aquatic therapy, the patient's pain level before beginning the program, the current pain level and future goals for the patient's care.
• Indication of pool water temperature for each session.

Procedure code 97113 represents aquatic therapy with therapeutic exercise.  Payment for procedure code 97113 includes whirlpool (97022) and/or Hubbard tank (97036). Separate payment will not be made for 97022 or 97036 in addition to 97113 for a single patient encounter.  Modifier 59 may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day. When modifier 59 is reported, the patient’s records must support its use in accordance with CPT guidelines.

Gait Training

Procedure code 97116 should be used to report gait training therapy. Gait training is a technique that restores a patient's normal stance, swing, speed, balance and sequence of muscle contractions for walking.

Generally accepted indications for gait training include:

• Foot drop resulting from stroke
• Herniated disc(s)
• Ankle, knee and/or hip replacement
• Traumatic amputations of the toe(s)

Documentation for gait training must demonstrate that the patient's gait was improved either by lengthening the gait or increasing the frequency of cadence lower-extremity.

Procedure code 97116 should not be used to report orthotics or prosthetics training. Orthotics training should be reported using procedure code 97760. Prosthetics training should be reported using procedure code 97761.

Vestibular Rehabilitation Therapy

Vestibular rehabilitation therapy generally refers to an individualized rehabilitation program for the treatment of patients with vertigo and disequilibrium. The therapy is designed to address the patient's specific complaints and functional deficits and may include specific exercises, gait training, balance retraining, and patient education and instructions for a home exercise program designed to decrease dizziness, improve balance function, and increase general activity levels. A vestibular rehabilitation program typically last 45 minutes per session and is prescribed 1-2 times per week. In general, patients remain in the program 4-8 weeks.

A vestibular rehabilitation program may be considered medically necessary for patients with vertigo, disequilibrium, and balance deficits related to the following conditions:

• peripheral vestibular disorders (e.g., labyrinthitis, neuritis, benign paroxysmal positional vertigo, post vestibular surgical symptoms, and bilateral vestibular loss),
• mixed {peripheral and central vestibular disorders, and
• central causes of vertigo (e.g., CVA, multiple sclerosis, and mild traumatic brain injury)

If none of these conditions are reported, a vestibular rehabilitation program is considered not medically necessary, and therefore, not covered.  A participating, preferred or network 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 should be maintained in the provider's records.

A vestibular rehabilitation program may include the following physical medicine or occupational therapy modalities:

• Physical medicine evaluation and re-evaluation (97001, 97002),
• Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility (97110),
• Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and proprioception (97112),
• Gait training (includes stair climbing) (97116), and
• Therapeutic activities, direct (one on one) patient contact by the provider (use of dynamic activities to improve functional performance) (97530)

The following services are considered experimental/investigational or not medically necessary and therefore, not covered:

Dry Hydro Massage (97799)

Hydrotherapy refers to the use of water in the treatment of disease or trauma.  The patient lies back, completely clothed, on the surface of a hydrotherapy table.  Under the surface is a mattress filled with heated water.  A pump propels the water toward the patient through hydro-jets.  The pressure of the water against the patient’s body provides the massage.  A primary wave and a lighter secondary wave combine to produce a deep tissue massage to all areas of the spine simultaneously.  The therapy can be applied to nearly every body part by changing the individual’s position on the table.  This is unattended hands-free massage.

Dry hydro massage is considered not medically necessary.  Effective January 26, 2009, a participating, preferred or network 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 should be maintained in the provider's records.

The Profiler and Aqua PT are considered forms of dry hydro massage.

Electromagnetic Stimulation (Code 97799)

Date Last Reviewed 01/2009

Electromagnetic therapy devices create a magnetic field that penetrates the body creating nerve impulses that innervate smooth and striated muscles.  This type of therapy is used for the treatment of bulk muscle excitation, relaxation of muscle spasms, maintaining or increasing range of motion, prevention or retardation of disuse atrophy, muscle re-education, increasing local blood circulation, and immediate post-surgical stimulation of the calf muscles to prevent venous thrombosis.

Because the effectiveness of electromagnetic stimulation has not been established, this service is considered experimental/investigational.  A participating, preferred or network provider may bill the member for the denied therapy.

Equestrian/Hippotherapy (S8940)

Date Last Reviewed - 10/2010

Hippotherapy (Equestrian therapy) is a treatment modality that utilizes the movement of a horse as a tool to improve the patient’s neuromuscular function.   Hippotherapy is used for patients with compromised neuromuscular function, e.g., cerebral palsy.  The horse’s walk provides sensory stimulation through its rhythmic, repetitive movement.  The goals of hippotherapy are to combine this treatment modality with other therapeutic modalities to improve balance, posture , mobility and function.

Hippotherapy is considered experimental/investigational.  Scientific evidence does not demonstrate the efficacy of this service.  A participating, preferred, or network provider can bill the member for the denied service.

Low-Intensity Pulsed Ultrasound (Hands-Free Ultrasound) (97799)

Date last Reviewed - 02/2009

Hands-free ultrasound is used as an alternative to traditional manual ultrasound.  The lower intensity, pulsed treatment allows for a longer treatment time.  In traditional ultrasound, the therapist manually moves the soundhead over the treatment area, whereas the stationary soundhead used in this method of ultrasound therapy does not require that the therapist remain with the patient during the duration of the treatment.

Hands-free ultrasound therapy is considered investigational.  There is a lack of clinical studies showing that lower intensity ultrasound therapy is as effective as traditional ultrasound.  Participating, preferred, and network providers can bill the patient for the denied service.  Use procedure code 97799 (Unlisted physical medicine/rehabilitation service or procedure) to report this service.

Horizontal Therapy (97799)

Date Last Reviewed - 01/2009

Horizontal therapy is a form of bioelectrical stimulation.  During horizontal therapy, electric current moves through tissues horizontally rather than vertically.

Horizontal therapy is considered experimental/investigational.  Further studies are needed to determine the long-term efficacy of this modality.  A participating, preferred, or network provider can bill the member for the denied service.  Use procedure code 97799 (Unlisted physical rehabilitation service or procedure) to report this service.

Low-Level Laser Therapy (S8948) (Cold Laser Therapy)

Date Last Reviewed - 10/2009

Low-level laser therapy is the non-invasive application of red or cold (subthermal) laser light to injuries or wounds to improve soft tissue healing and relieve both acute and chronic pain (e.g., wound healing, carpal tunnel syndrome, and pain management).

Low-level laser therapy is considered experimental/investigational.  This service is still being performed in a clinical trial setting with no long-term outcomes available.  Further studies are needed to determine the long-term efficacy of this modality.  A participating, preferred, or network provider can bill the member for the denied service.

NOTE:
For information on sensory integration techniques, refer to Medical Policy Bulletin Y-2.

For information on cognitive rehabilitation, refer to Medical Policy Bulletin Y-21.

For information on interferential stimulation, refer to Medical Policy Bulletin E-45.

For information on electromagnetic therapy provided for the treatment of urinary incontinence, see Medical Policy Bulletin, Y-12.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.

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