L31536 L31542  HOME HEALTH-PHYSICAL THERAPY

 

Region IV J11HH-11-013-L

 

01/01/2013

 

Indications and Limitations of Coverage and/or Medical Necessity

• Although there is an overlap in services provided by physical and occupational therapists, this policy addresses only physical therapy.

 

• Physical therapy services are part of a constellation of rehabilitative services designed to improve or restore physical functioning as well as to prevent injury, impairments, activity limitations, participation restrictions and disability following disease, injury or loss of a body part.

• Impairments, activity limitations and disabilities are addressed by the examination, evaluation and development of a plan of care that may include implementation of therapeutic interventions tailored to the specific needs of the individual patient to achieve specific goals and outcomes.

• The specific interventions that may be utilized are therapeutic exercises to strengthen muscles, maintain or restore motion, integumentary repair and protection techniques, physical agents and mechanical modalities such as heat, cold, electrotherapeutic modalities, ultrasound and hydrotherapy, manual therapy and functional training or retraining an individual to perform the activities of daily living.

 

• General Physical Therapy Guidelines:

 

o The service of a physical therapist, speech-language pathologist, or occupational therapist is a skilled therapy service if the inherent complexity of the service is such that it can be performed safely and/or effectively only by or under the general supervision of a skilled therapist.

 To be covered, the skilled services must also be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury.

 It is necessary to determine whether individual therapy services are skilled and whether, in view of the patient's overall condition, skilled management of the services provided is needed.

o The development, implementation, management, and evaluation of a patient care plan based on the physician's orders constitute skilled therapy services when, because of the patient's condition, those activities require the skills of a qualified therapist to ensure the effectiveness of the treatment goals and ensure medical safety.

 Where the skills of a therapist are needed to manage and periodically reevaluate the appropriateness of a maintenance program because of an identified danger to the patient, such services would be covered, even if the skills of a therapist were not needed to carry out the activities performed as part of the maintenance program.

o While a patient's particular medical condition is a valid factor in deciding if skilled therapy services are needed, a patient'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 therapist are needed to treat the illness or injury, or whether the services can be carried out by nonskilled personnel.

o A service that is ordinarily considered nonskilled could be considered a skilled therapy service in cases in which there is clear documentation that, because of special medical complications, skilled rehabilitation personnel are required to perform the service.

 However, the importance of a particular service to a patient or the frequency with which it must be performed does not, by itself, make a nonskilled service into a skilled service.

o The physician or qualified therapist must document the patient's functional limitations in terms that are objective and measurable.

o Rehabilitation Services for Vision Impairment

 The coverage criteria and definition of rehabilitation services for vision impairment (Low Vision) is found in Transmittal AB-02-078, dated, May 28, 2002, Change Request 2083.

 

 

SPECIFIC PROCEDURE AND MODALITY GUIDELINES:

• FABRICATION/APPLICATION OF SPLINTS AND STRAPPING

 

o Fabrication and application as appropriate of splints and strapping (e.g., the use of elastic wraps, heavy cloth, and adhesive tape) are used to enhance performance of tasks or movements, support weak or ineffective joints or muscles, reduce/correct joint limitations/deformities, and/or protect body parts from injury.

 The splints and strapping are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of patient’s needs and social/cultural environments.

o The physical therapist targets the problems in performance of movements or tasks and selects (or fabricates) the most appropriate device or equipment, then fits it and trains the patient and/or caregivers in its use and application.

 The goal is for the patient to function at a higher level by decreasing functional limitations.

o The simple application of a commercial splint or brace will not be considered in this section.

 

• Application long arm splint (CPT code 29105):

o Maybe indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, contractures or other deformities involving soft tissue.

 

• Application of short arm splint (CPT code 29125 and 29126):

o Maybe indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, contractures or other deformities involving soft tissue.

 

• Application of finger splint (CPT code 29130 and 29131):

o Maybe indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendinitis, post-op reconstruction, contractures or other deformities involving soft tissue.

 

 

• Strapping of thorax (CPT code 29200):

o Maybe indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

 

• Strapping of low back (CPT code 29799):

o Maybe indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

 

• Strapping of shoulder (e.g., Velpuau)(CPT code 29240):

o Maybe indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

 

• Strapping of elbow or wrist (CPT code 29260):

o Maybe indicated for the elbow and wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

 

• Strapping of hand or finger (CPT code 29280):

o May be indicated when there is involvement of the hand or finger(s) in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissues.

 

• Application of long leg splint (CPT code 29505):

o Maybe indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

 

• Application of short leg splint (CPT code 29515):

o Maybe indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.

 

• Strapping of hip (CPT code 29520):

o Maybe indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

 

• Strapping of knee (CPT code 29530):

o Maybe indicated when there is involvement of the thigh, knee, or lower leg in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

 

• Strapping of ankle and/or foot (CPT code 29540):

o Maybe indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

 

• Strapping of toes (CPT code 29550):

o Maybe indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.

 

• Application of unna boot (CPT code 29580):

o A dressing for ulcers resulting from venous insufficiency, consisting of a paste made from gelatin zinc oxide and glycerin which is applied to the leg then covered with a spiral bandage, this in turn being given a coat of the paste.

 The process is repeated until satisfactory rigidity is attained.

o Biofeedback training any method and biofeedback training perineal muscles, anorectal or urethral sphincter (CPT codes 90901 and 90911).

o The coverage criteria and definition of biofeedback therapy is found in the CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §§30.1 and 30.1.1.

o "Biofeedback is a tool utilized by physical therapists to assist with muscle training.

 This includes facilitation of muscles that are demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can be visual or auditory."

 

• Muscle testing, manual (CPT Codes 95831-95834)

o The series of codes 95831-95834 are intended to report manual test of muscles or muscle groups for strength based on grading scales.

o Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk (CPT code 95831)

o 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.

o Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side (CPT code 95832)

o Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands or including hands (CPT codes 95833 and 95834)

o The measurement of muscle performance using manual muscle testing only.

 

• Range of Motion Measurements (CPT codes 95851 and 95852):

o Determination of range of motion using a tape measure, flexible ruler, electronic device or goniometer.

 

• PT Evaluation (CPT code 97001) and PT Re-evaluation (CPT code 97002):

o Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities.

 Evaluation is warranted e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the plan of care, including goals and the selection of interventions.

 The time spent in evaluation does not count as treatment time.

o The initial examination has the following components:

 The patient history to include prior level of function

 Relevant systems review

 Tests and measures

 Current functional status (abilities and deficits)

 Evaluation of patient's, physician's and as appropriate the caregiver's goals

o Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent and duration of loss of function, prior functional level, social/environmental considerations, educational level, the patient's overall physical and cognitive health status, social/cultural supports, psychosocial factors and use of adaptive equipment.

 Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition.

 Physical therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, the living environment, prior level of function, the social/cultural supports, psychosocial factors, and use of adaptive equipment.

o Initial evaluations or reevaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized.

o Reevaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient’s condition or functional status that was not anticipated in the plan of care.

 Some regulations and state practice acts require reevaluation at specific intervals.

 A 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.

o Reevaluations are appropriate periodically to assess progress toward goals established in the plan of treatment, or to identify and establish interventions for newly developed impairments at least once every 30 days, for each therapy discipline.

 A reevaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.

 

• Designing and Implementing a Maintenance Program:

o If the patient's clinical condition requires the specialized skill, knowledge and judgment of a qualified therapist to design or establish a maintenance program related to the patient's illness or injury, in order to ensure the safety of the patient and the effectiveness of the program, such services are covered.

o During the last visit(s) for restorative treatment, the qualified therapist 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.

o Periodic evaluations of the patient and adjustments to a maintenance program may be covered if such require the specified skills of a qualified occupational therapist.

o Where a maintenance program is not established until after the rehabilitative therapy program has been completed, or where there was no rehabilitative therapy program, a qualified therapist's development of a maintenance program would be considered reasonable and necessary for the treatment of the patient's condition only when an identified danger to the patient exists.

o When designing or establishing a maintenance program, the qualified therapist must teach the patient or the patient's family or caregiver's necessary techniques, exercises or precautions as necessary to treat the illness or injury.

o The skills of a qualified therapist are needed to perform maintenance therapy:

 Where the clinical condition of the patient is such that the complexity of the therapy services required to maintain function involved the use of complex and sophisticated therapy procedures to be delivered by the therapist himself/herself (and not an assistant) or

 the clinical condition of the patient is such that the complexity of the therapy series required to maintain function must be delivered by the therapist himself/herself (and not an assistant) in order to ensure the patient's safety and to provide an effective maintenance program, then those reasonable and necessary services should be covered

o The amount, frequency, and duration of the services must be reasonable.

 

• Skilled Maintenance Therapy for Safety

o The development, implementation, management, and evaluation of a patient care plan based on the physician's orders constitute skilled therapy services when, because the patient's condition, those activities require the skills of a qualified therapist to ensure the effectiveness of the treatment goals and ensure medical safety.

o Where the skills of a therapist are needed to manage and periodically reevaluate the appropriateness of a maintenance program because of an identified danger to the patient, such services would be covered, even if the skills of a therapist were not needed to carry out the activities performed as part of the maintenance program.

 

• Hot or Cold Packs therapy (CPT code 97010):

o Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm and reduce inflammation and edema.

 Typically, cold packs are used for acute, painful conditions, and hot packs for subacute or chronic painful conditions.

o Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist.

 However, the skills, knowledge and judgment of a qualified physical therapist might be required in the giving of such treatments or baths in a particular case.

• e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications.

o Hot or cold packs applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not reasonable and necessary and therefore, are not covered.

 

• Mechanical Traction therapy (CPT code 97012):

o Traction is generally limited to the cervical or lumbar spine with the hope of relieving pain in or originating from those areas.

o Specific indications for the use of Mechanical Traction include:

 Cervical and/or lumbar radiculopathy

 Back disorders such as disc herniation, lumbago, and sciatica

 

• Vasopneumatic Device Therapy (CPT code 97016):

o 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.

o Specific indications for the use of vasopneumatic devices include:

 Reduction of edema after acute injury

 Lymphedema of an extremity

 Education on the use of a lymphedema pump for home use

o Note: Further treatment of lymphedema by a physical therapist after the educational visits are generally not reasonable and necessary. Generally, education can be completed in three visits.

 

• Paraffin Bath (CPT code 97018):

o Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands, and feet.

o Heat treatments and baths of this type ordinarily do not require the skills of a qualified physical therapist.

 However, the skills, knowledge and judgment of a qualified physical therapist might be required in the giving of such treatment or baths in a particular case.

• e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications.

 

• Whirlpool (CPT code 97022)

o Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified physical therapist.

o However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths.

 e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds or other complications.

o Also, if such treatments are given prior to but as an integral part of a skilled physical therapy procedure, they would be considered part of the physical therapy service.

 

 

• Diathermy Treatment (CPT code 97024):

o The coverage criteria and definition of Diathermy Treatment is found in the CMS Manual System, Pub. 100-03, Medicare National Coverage Determination, Chapter 1, Part 2, §150.5 and Part 4, §240.3.

 

• Infrared Therapy (CPT code 97026):

o The coverage criteria and definition of Infrared Therapy is found in the CMS Manual System, Pub. 100-03, Medicare National Coverage Determination, Chapter 1, Part 4,§270.6

 

• Electrical Stimulation Therapy (CPT code 97032)

o CPT code 97032 requires "visual, verbal and/or manual contact" (i.e. constant attendance).

o Effective for claims with dates of service on or after June 8, 2012, CMS no longer allows coverage under any circumstance except in the setting of an approved clinical study under coverage with evidence development (CED) for TENS used for treatment of chronic low back pain (CLBP) which has persisted for more than three months and is not a manifestation of a clearly defined and generally recognizable primary disease entity.

 

• Electromagnetic Therapy (HCPCS code G0329)

o Electromagnetic therapy criteria and definition are found in the CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.1

 

• Contrast Bath Therapy (CPT code 97034)

o Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold.

 Although a variety of applications are possible, contrast baths often are used in treatment to decrease edema and inflammation.

o The use of Contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.

o Specific indications for the use of contrast baths include:

 The patient having rheumatoid arthritis or other inflammatory arthritis

 The patient having reflex sympathetic dystrophy

 The patient having a sprain or strain resulting from an acute injury

o Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified physical therapist.

 However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths.

• e.g., where the patient’s condition is complicated by circulatory deficiency, areas of desensitization, open wounds or other complications.

 Also, if such treatments are given prior to but as an integral part of a skilled physical therapy procedure, they would be considered part of the physical therapy service.

 

• Ultrasound Therapy (CPT code 97035)

o 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 can receive an even greater dosage of ultrasound, as much as 30% more.

 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 they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted range of motion.

o The application of ultrasound is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.

o Specific indications for the use of ultrasound application include:

 The patient having tightened structures limiting joint motion that require an increase in extensibility

 The patient having symptomatic soft tissue calcification

 The patient having neuromas

o Note: Ultrasound application is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.

 

• GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES:

o Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services.

o Use of these procedures requires that the services be rendered under the supervision of a physical therapist.

o Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions.

 The expected goals documented in the written plan of treatment, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary.

 Therefore, since any one or a combination of more than one of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal.

o Services provided concurrently by a physical therapist and occupational therapist may be covered if separate and distinct goals are documented in the treatment plans.

o Requires (one on one) direct patient contact

 

• Therapeutic Exercises (CPT code 97110):

o Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching and strengthening).

o A physical therapist may use this code when addressing impairments of exercise tolerance due to cardiopulmonary impairments.

 Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.

o Therapeutic exercise is considered reasonable and necessary if at least one of the following conditions is present and documented:

 The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint range of motion, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance

 The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, range of motion, or endurance as part of activities of daily living training, or reeducation.

o Documentation for therapeutic exercise typically includes objective loss of joint motion, strength, and/or mobility

 (e.g., degrees of motion, strength grades, and levels of assistance).

 

• Neuromuscular Reeducation (CPT code 97112):

o This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception

 (e.g., proprioceptive neuromuscular facilitation, BAP’s boards, and desensitization techniques).

o Neuromuscular reeducation may be considered reasonable and necessary for impairments, which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, tilt table or standing table, hypo/hypertonicity) and improvement of motor control and motor learning.

 

 

• Gait Training Therapy (CPT code 97116):

o This procedure may be reasonable and necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.

o Specific indications for gait training include:

 The patient having suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation

 The patient having recently suffered a musculoskeletal trauma, requiring ambulation re-education

 The patient having a chronic, progressively debilitating condition for which safe ambulation has recently become a concern

 The patient having had an injury or condition that requires instruction in the use of a walker, crutches, or cane

 The patient having been fitted with a brace/lower limb prosthesis and requires instruction in ambulation

 The patient having a condition that requires retraining in stairs/steps or chair transfer in addition to general ambulation

o Gait training is not considered reasonable and necessary when the patient’s walking ability is not expected to improve.

o Repetitious exercises to improve gait, or to maintain strength and endurance, and assistive walking are appropriately provided by supportive personnel.

 e.g., aides or nursing personnel, and do not require the skills of a physical therapist.

o Thus, such services are not skilled therapy.

 

• Massage Therapy (CPT code 97124):

o Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes.

 Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment as well as a treatment tool.

o Massage therapy, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least one of the following conditions is present and documented:

 The patient having paralyzed musculature contributing to impaired circulation.

 The patient having sensitivity of tissues to pressure.

 The patient having tight muscles resulting in shortening and/or spasticity of affected muscles.

 The patient having abnormal adherence of tissue to surrounding tissue.

 The patient requiring relaxation in preparation for neuromuscular re-education or therapeutic exercise.

 The patient having contractures and decreased range of motion.

o In most cases, postural drainage and pulmonary exercises can be carried out safely and effectively by nursing personnel.

 To be considered for payment, the physical therapist must identify the intervention that is best suited for the patient, taking into consideration the patient’s condition and any contraindications that may be present.

 As there can be an overlap of skills between disciplines, i.e., respiratory therapy, skilled nursing and physical therapy, the documentation must clearly support the need for the intervention to be provided by the physical therapist.

 

• Manual Therapy (CPT code 97140):

o Joint Mobilization (Peripheral or Spinal)

 This procedure may be considered reasonable and necessary if restricted joint motion is present and documented.

• It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.

o Soft Tissue Mobilization

 This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems.

• Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue.

 Soft tissue mobilization can be considered reasonable and necessary if at least one of the following conditions is present and documented:

• The patient having restricted joint or soft tissue motion in an extremity, neck or trunk.

• Treatment being a necessary adjunct to other physical therapy interventions such as 97110, 97112 or 97530.

 

• Orthotics Training (CPT code 97760):

o This procedure may be considered reasonable and necessary if there is an indication for education on the application of the orthotic, the orthotic is in the home and the functional use of the orthotic is documented.

o Generally, orthotic training can be completed in three visits; however, for modification of the orthotic due to healing of tissues, change in edema, or impairment in skin integrity, additional visits may be required.

o The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training (CPT code 97116) or self-care/home management training (CPT code 97535).

o The patient is capable of being trained to use the particular device prescribed in an appropriate manner.

 In some cases the patient may not be able to perform this function, but a responsible individual can be trained to use the device.

 

• Prosthetic Training (CPT code 97761):

o This procedure may be considered reasonable and necessary if there is an indication for education on the application of the prosthesis, the prosthesis is in the home and the functional use of the prosthetic is documented

o The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training (CPT code 97116) or self-care/home management training (CPT code 97535)

o Periodic revisits beyond the third month would require documentation to support medical necessity.

 

• Therapeutic Activities (CPT code 97530):

o Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involve movement.

 Movement activities can be for a specific body part or could involve the entire body.

 This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching, and overhead activities) to improve functional performance in a progressive manner.

 The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination.

 They require the skills of a physical therapist and are designed to address a specific functional need of the patient.

 These dynamic activities must be part of an active treatment plan and be directed at a specific outcome.

o In order for therapeutic activities to be covered, the following requirements must be met:

 The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning

 The patient’s condition being such that he/she is unable to perform therapeutic activities except under the direct supervision of a physician or physical therapist

 There being a clear correlation between the type of exercise performed and the patient’s underlying medical condition for which the therapeutic activities were prescribed

 

• Self-Care/Home Management Training (CPT code 97535):

o The coverage criteria and definition of self-care management training is found in the CMS Manual System, Pub 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.1

o "Self-care/home management training (97535) describes a group of interventions that focuses on activities of daily living skills and compensatory activities needed to achieve independence.

 These include activities such as dressing, bathing, food preparation, and cooking.

 The patient/client may require adaptive equipment and/or assistive technology in the home environment.

 This code includes training the patient/client and/or caregiver in the use of the equipment."

o 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.

 

• Community/Work Reintegration (CPT code 97537,97545, and 97546):

o Physical therapy services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1)(A) of the Social Security Act.

 

• Wheelchair Management Training (CPT code 97542):

o This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who are wheelchair bound may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.

o This procedure is reasonable and necessary only when it requires the skills of a physical therapist is designed to address specific needs of the patient, and must be part of an active treatment plan directed at a specific goal.

o The patient and/or caregiver must have the capacity to learn from instructions.

o Typically three to four sessions should be sufficient to teach the patient and/or caregiver these skills.

o When billing 97542 for wheelchair propulsion training, documentation must relate the training to expected functional goals that are attainable by the patient and/or caregiver.

 

• Prosthetic Checkout (CPT Code 97762):

o These assessments are reasonable and necessary for "established patients who have already received the orthotic or prosthetic device (permanent or temporary)."

o These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls).

o These assessments may be reasonable and necessary for determining "the patient’s response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, underwrap, or socks and determining the patient's tolerance to any dynamic forces being applied."

 

• Physical Performance Test or Measurement (CPT code 97750):

o This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific treatment plan, or to determine a patient’s functional capacity.

 

 

Coding Information

 

Bill Type Codes:

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

032x Home Health - Inpatient (plan of treatment under Part B only)

033x Home Health - Outpatient (plan of treatment under Part A, including DME under Part A)

 

 

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

0420  Physical Therapy - General Classification

0421  Physical Therapy - Visit

0424  Physical Therapy - Evaluation or Re-evaluation

0429  Physical Therapy - Other Physical Therapy

 

 

CPT/HCPCS Codes

• As of July 1999, Physical Therapists must report time spent with the patient in 15-minute increments.

• The following code should be used by Physical Therapy:

G0151 HHCP-serv of pt,ea 15 min

Other CPT codes found in this policy are for informational and descriptive use only.

29105 Apply long arm splint

29125 Apply forearm splint

29126 Apply forearm splint

29130 Application of finger splint

29131 Application of finger splint

29200 Strapping of chest

29240 Strapping of shoulder

29260 Strapping of elbow or wrist

29280 Strapping of hand or finger

29505 Application long leg splint

29515 Application lower leg splint

29520 Strapping of hip

29530 Strapping of knee

29540 Strapping of ankle and/or ft

29550 Strapping of toes

29580 Application of paste boot

29799 Casting/strapping procedure

90901 Biofeedback train any meth

90911 Biofeedback peri/uro/rectal

95831 Limb muscle testing manual

95832 Hand muscle testing manual

95833 Body muscle testing manual

95834 Body muscle testing manual

95851 Range of motion measurements

95852 Range of motion measurements

97001 Pt evaluation

97002 Pt re-evaluation

97010 Hot or cold packs therapy

97012 Mechanical traction therapy

97016 Vasopneumatic device therapy

97018 Paraffin bath therapy

97022 Whirlpool therapy

97024 Diathermy e.g. microwave

97026 Infrared therapy

97032 Electrical stimulation

97034 Contrast bath therapy

97035 Ultrasound therapy

97110 Therapeutic exercises

97112 Neuromuscular reeducation

97116 Gait training therapy

97124 Massage therapy

97140 Manual therapy 1/> regions

97530 Therapeutic activities

97535 Self-care management training

97537 Community/work reintegration

97542 Wheelchair management training

97545 Work hardening

97546 Work hardening add-on

97750 Physical performance test

97755 Assistive technology assess

97760 Orthotic mgmt and training

97761 Prosthetic training

97762 C/o for orthotic/prosth use

G0329 Electromagntic tx for ulcers

 

 

ICD-9 Codes that Support Medical Necessity

 

138 LATE EFFECTS OF ACUTE POLIOMYELITIS

331.6 CORTICOBASAL DEGENERATION

333.71 ATHETOID CEREBRAL PALSY

333.72 ACUTE DYSTONIA DUE TO DRUGS

333.79 OTHER ACQUIRED TORSION DYSTONIA

333.83 SPASMODIC TORTICOLLIS

333.85 SUBACUTE DYSKINESIA DUE TO DRUGS

333.91 STIFF-MAN SYNDROME

337.21 REFLEX SYMPATHETIC DYSTROPHY OF THE UPPER LIMB

337.22 REFLEX SYMPATHETIC DYSTROPHY OF THE LOWER LIMB

337.29 REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE

337.3 AUTONOMIC DYSREFLEXIA

337.9 UNSPECIFIED DISORDER OF AUTONOMIC NERVOUS SYSTEM

342.01 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE

342.02 FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

342.11 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE

342.12 SPASTIC HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

342.81 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE

342.82 OTHER SPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

342.91 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING DOMINANT SIDE

342.92 UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE

344.01 - 344.09 QUADRIPLEGIA C1-C4 COMPLETE - OTHER QUADRIPLEGIA

344.1 PARAPLEGIA

344.2 DIPLEGIA OF UPPER LIMBS

344.31 - 344.32 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE - MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

344.41 - 344.42 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE - MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SDE

344.60 - 344.61

CAUDA EQUINA SYNDROME WITHOUT NEUROGENIC BLADDER - CAUDA EQUINA SYNDROME WITH NEUROGENIC BLADDER

344.81 LOCKED-IN STATE

344.89 OTHER SPECIFIED PARALYTIC SYNDROME

351.0 BELL'S PALSY

353.0 - 353.8 BRACHIAL PLEXUS LESIONS - OTHER NERVE ROOT AND PLEXUS DISORDERS

354.0 - 354.8 CARPAL TUNNEL SYNDROME - OTHER MONONEURITIS OF UPPER LIMB

355.0 - 355.8 LESION OF SCIATIC NERVE - MONONEURITIS OF LOWER LIMB UNSPECIFIED

356.0 HEREDITARY PERIPHERAL NEUROPATHY

356.1 PERONEAL MUSCULAR ATROPHY

356.2 HEREDITARY SENSORY NEUROPATHY

356.3 REFSUM'S DISEASE

356.4 IDIOPATHIC PROGRESSIVE POLYNEUROPATHY

356.8 OTHER SPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY

357.0 ACUTE INFECTIVE POLYNEURITIS

357.2 POLYNEUROPATHY IN DIABETES

358.30 LAMBERT-EATON SYNDROME, UNSPECIFIED

358.31 LAMBERT-EATON SYNDROME IN NEOPLASTIC DISEASE

358.39 LAMBERT-EATON SYNDROME IN OTHER DISEASES CLASSIFIED ELSEWHERE

359.21 MYOTONIC MUSCULAR DYSTROPHY

359.22 MYOTONIA CONGENITAL

359.23 MYOTONIC CHONDRODYSTROPHY

359.24 DRUG INDUCED MYOTONIA

359.29 OTHER SPECIFIED MYOTONIC DISORDER

359.71 INCLUSION BODY MYOSITIS

359.79 OTHER INFLAMMATORY AND IMMUNE MYOPATHIES, NEC

386.11 BENIGN PAROXYSMAL POSITIONAL VERTIGO

438.21 HEMIPLEGIA AFFECTING DOMINANT SIDE

438.22 HEMIPLEGIA AFFECTING NONDOMINANT SIDE

438.31 MONOPLEGIA OF UPPER LIMB AFFECTING DOMINANT SIDE

438.32 MONOPLEGIA OF UPPER LIMB AFFECTING NONDOMINANT SIDE

438.41 MONOPLEGIA OF LOWER LIMB AFFECTING DOMINANT SIDE

438.42 MONOPLEGIA OF LOWER LIMB AFFECTING NONDOMINANT SIDE

438.52 OTHER PARALYTIC SYNDROME AFFECTING NONDOMINANT SIDE

438.53 OTHER PARALYTIC SYNDROME BILATERAL

438.6 ALTERATIONS OF SENSATIONS

438.81 APRAXIA CEREBROVASCULAR DISEASE

438.82 DYSPHAGIA CEREBROVASCULAR DISEASE

438.83 FACIAL WEAKNESS

438.84 ATAXIA

438.85 VERTIGO

454.0 - 454.2 VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER - VARICOSE VEINS OF LOWER EXTREMITIES WITH ULCER AND INFLAMMATION

454.8 VARICOSE VEINS OF LOWER EXTREMITIES WITH OTHER COMPLICATIONS

457.0 POSTMASTECTOMY LYMPHEDEMA SYNDROME

457.1 OTHER LYMPHEDEMA

459.31 CHRONIC VENOUS HYPERTENSION WITH ULCER

459.33 CHRONIC VENOUS HYPERTENSION WITH ULCER AND INFLAMMATION

514 PULMONARY CONGESTION AND HYPOSTASIS

625.6 STRESS INCONTINENCE FEMALE

681.00 - 681.11 UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER - ONYCHIA AND PARONYCHIA OF TOE

682.0 - 682.7 CELLULITIS AND ABSCESS OF FACE - CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES

683 ACUTE LYMPHADENITIS

707.00 - 707.8 PRESSURE ULCER, UNSPECIFIED SITE - CHRONIC ULCER OF OTHER SPECIFIED SITES

707.9 CHRONIC ULCER OF UNSPECIFIED SITE

709.2 SCAR CONDITIONS AND FIBROSIS OF SKIN

714.0 - 714.89 RHEUMATOID ARTHRITIS - OTHER SPECIFIED INFLAMMATORY POLYARTHROPATHIES

714.9 UNSPECIFIED INFLAMMATORY POLYARTHROPATHY

715.00 - 715.09 OSTEOARTHROSIS GENERALIZED INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS GENERALIZED INVOLVING MULTIPLE SITES

715.10 - 715.18 OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS LOCALIZED PRIMARY INVOLVING OTHER SPECIFIED SITES

715.20 - 715.28 OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS LOCALIZED SECONDARY INVOLVING OTHER SPECIFIED SITES

715.30 - 715.38 OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS LOCALIZED NOT SPECIFIED WHETHER PRIMARY OR SECONDARY INVOLVING OTHER SPECIFIED SITES

715.80 - 715.89 OSTEOARTHROSIS INVOLVING OR WITH MORE THAN ONE SITE BUT NOT SPECIFIED AS GENERALIZED AND INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS INVOLVING OR WITH MULTIPLE SITES BUT NOT SPECIFIED AS GENERALIZED

715.90 - 715.98 OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING UNSPECIFIED SITE - OSTEOARTHROSIS UNSPECIFIED WHETHER GENERALIZED OR LOCALIZED INVOLVING OTHER SPECIFIED SITES

716.01 - 716.04 KASCHIN-BECK DISEASE INVOLVING SHOULDER REGION - KASCHIN-BECK DISEASE INVOLVING HAND

716.11 - 716.14 TRAUMATIC ARTHROPATHY INVOLVING SHOULDER REGION - TRAUMATIC ARTHROPATHY INVOLVING HAND

716.21 - 716.24 ALLERGIC ARTHRITIS INVOLVING SHOULDER REGION - ALLERGIC ARTHRITIS INVOLVING HAND

716.41 - 716.44 TRANSIENT ARTHROPATHY INVOLVING SHOULDER REGION - TRANSIENT ARTHROPATHY INVOLVING HAND

716.51 - 716.54

UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING SHOULDER REGION - UNSPECIFIED POLYARTHROPATHY OR POLYARTHRITIS INVOLVING HAND

716.61 - 716.64UNSPECIFIED MONOARTHRITIS INVOLVING SHOULDER REGION - UNSPECIFIED MONOARTHRITIS INVOLVING HAND

716.81 - 716.84 OTHER SPECIFIED ARTHROPATHY INVOLVING SHOULDER REGION - OTHER SPECIFIED ARTHROPATHY INVOLVING HAND

718.41 - 718.49 CONTRACTURE OF JOINT OF SHOULDER REGION - CONTRACTURE OF JOINT OF MULTIPLE SITES

718.51 - 718.59 ANKYLOSIS OF JOINT OF SHOULDER REGION - ANKYLOSIS OF JOINT OF MULTIPLE SITES

719.41 - 719.49 PAIN IN JOINT INVOLVING SHOULDER REGION - PAIN IN JOINT INVOLVING MULTIPLE SITES

719.51 - 719.59 STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING SHOULDER REGION - STIFFNESS OF JOINT NOT ELSEWHERE CLASSIFIED INVOLVING MULTIPLE SITES

719.61 - 719.69 OTHER SYMPTOMS REFERABLE TO JOINT OF SHOULDER REGION - OTHER SYMPTOMS REFERABLE TO JOINT OF MULTIPLE SITES

719.7 DIFFICULTY IN WALKING

720.2 SACROILIITIS NOT ELSEWHERE CLASSIFIED

722.0 DISPLACEMENT OF CERVICAL INTERVERTEBRAL DISC WITHOUT MYELOPATHY

722.10 DISPLACEMENT OF LUMBAR INTERVERTEBRAL DISC WITHOUT MYELOPATHY

722.11 DISPLACEMENT OF THORACIC INTERVERTEBRAL DISC WITHOUT MYELOPATHY

722.81 - 722.83 POSTLAMINECTOMY SYNDROME OF CERVICAL REGION - POSTLAMINECTOMY SYNDROME OF LUMBAR REGION

723.1 CERVICALGIA

723.2 CERVICOCRANIAL SYNDROME

723.3 CERVICOBRACHIAL SYNDROME (DIFFUSE)

723.4 BRACHIAL NEURITIS OR RADICULITIS NOS

723.5 TORTICOLLIS UNSPECIFIED

724.03 SPINAL STENOSIS, LUMBAR REGION, WITH NEUROGENIC CLAUDICATION

724.1 PAIN IN THORACIC SPINE

724.2 LUMBAGO

724.3 SCIATICA

724.4 THORACIC OR LUMBOSACRAL NEURITIS OR RADICULITIS UNSPECIFIED

724.5 BACKACHE UNSPECIFIED

724.6 DISORDERS OF SACRUM

724.8 OTHER SYMPTOMS REFERABLE TO BACK

724.9 OTHER UNSPECIFIED BACK DISORDERS

725 POLYMYALGIA RHEUMATICA

726.0 ADHESIVE CAPSULITIS OF SHOULDER

726.10 DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION UNSPECIFIED

726.11 - 726.12 CALCIFYING TENDINITIS OF SHOULDER - BICIPITAL TENOSYNOVITIS

726.13 PARTIAL TEAR OF ROTATOR CUFF

726.19 OTHER SPECIFIED DISORDERS OF BURSAE AND TENDONS IN SHOULDER REGION

726.2 OTHER AFFECTIONS OF SHOULDER REGION NOT ELSEWHERE CLASSIFIED

726.30 ENTHESOPATHY OF ELBOW UNSPECIFIED

726.31 MEDIAL EPICONDYLITIS

726.32 LATERAL EPICONDYLITIS

726.33 OLECRANON BURSITIS

726.39 OTHER ENTHESOPATHY OF ELBOW REGION

727.00 SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED

727.01 SYNOVITIS AND TENOSYNOVITIS IN DISEASES CLASSIFIED ELSEWHERE

727.02 GIANT CELL TUMOR OF TENDON SHEATH

727.03 TRIGGER FINGER (ACQUIRED)

727.04 RADIAL STYLOID TENOSYNOVITIS

727.05 OTHER TENOSYNOVITIS OF HAND AND WRIST

727.06 TENOSYNOVITIS OF FOOT AND ANKLE

727.3 OTHER BURSITIS DISORDERS

727.50 - 727.59

RUPTURE OF SYNOVIUM UNSPECIFIED - OTHER RUPTURE OF SYNOVIUM

727.60 - 727.69 NONTRAUMATIC RUPTURE OF UNSPECIFIED TENDON - NONTRAUMATIC RUPTURE OF OTHER TENDON

727.81 CONTRACTURE OF TENDON (SHEATH)

728.2 MUSCULAR WASTING AND DISUSE ATROPHY NOT ELSEWHERE CLASSIFIED

728.3 OTHER SPECIFIC MUSCLE DISORDERS

728.4 LAXITY OF LIGAMENT

728.5 HYPERMOBILITY SYNDROME

728.6 CONTRACTURE OF PALMAR FASCIA

728.71 - 728.79 PLANTAR FASCIAL FIBROMATOSIS - OTHER FIBROMATOSES OF MUSCLE LIGAMENT AND FASCIA

728.81 - 728.85 INTERSTITIAL MYOSITIS - SPASM OF MUSCLE

728.87 MUSCLE WEAKNESS (GENERALIZED)

728.89 OTHER DISORDERS OF MUSCLE LIGAMENT AND FASCIA

729.0 RHEUMATISM UNSPECIFIED AND FIBROSITIS

729.1 - 729.2 MYALGIA AND MYOSITIS UNSPECIFIED - NEURALGIA NEURITIS AND RADICULITIS UNSPECIFIED

729.4 FASCIITIS UNSPECIFIED

729.5 PAIN IN LIMB

729.71 NONTRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY

729.72 NONTRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY

729.81 SWELLING OF LIMB

729.90 - 729.99

DISORDERS OF SOFT TISSUE, UNSPECIFIED - OTHER DISORDERS OF SOFT TISSUE

732.0 - 732.9 JUVENILE OSTEOCHONDROSIS OF SPINE - UNSPECIFIED OSTEOCHONDROPATHY

733.10 - 733.19 PATHOLOGICAL FRACTURE UNSPECIFIED SITE - PATHOLOGICAL FRACTURE OF OTHER SPECIFIED SITE

733.40 - 733.49 ASEPTIC NECROSIS OF BONE SITE UNSPECIFIED - ASEPTIC NECROSIS OF OTHER BONE SITES

733.5 OSTEITIS CONDENSANS

733.81 MALUNION OF FRACTURE

733.82 NONUNION OF FRACTURE

733.90 DISORDER OF BONE AND CARTILAGE UNSPECIFIED

733.91 ARREST OF BONE DEVELOPMENT OR GROWTH

733.92 CHONDROMALACIA

733.93 STRESS FRACTURE OF TIBIA OR FIBULA

733.95 STRESS FRACTURE OF OTHER BONE

733.96 STRESS FRACTURE OF FEMORAL NECK

733.97 STRESS FRACTURE OF SHAFT OF FEMUR

733.98 STRESS FRACTURE OF PELVIS

733.99 OTHER DISORDERS OF BONE AND CARTILAGE

734 FLAT FOOT

735.0 - 735.9 HALLUX VALGUS (ACQUIRED) - UNSPECIFIED ACQUIRED DEFORMITY OF TOE

736.00 - 736.04 UNSPECIFIED DEFORMITY OF FOREARM EXCLUDING FINGERS - VARUS DEFORMITY OF WRIST (ACQUIRED)

736.05 WRIST DROP (ACQUIRED)

736.06 - 736.07 CLAW HAND (ACQUIRED) - CLUB HAND ACQUIRED

736.1 MALLET FINGER

736.20 - 736.29 UNSPECIFIED DEFORMITY OF FINGER - OTHER ACQUIRED DEFORMITIES OF FINGER

736.30 - 736.39 UNSPECIFIED ACQUIRED DEFORMITY OF HIP - OTHER ACQUIRED DEFORMITIES OF HIP

736.41 - 736.42 GENU VALGUM (ACQUIRED) - GENU VARUM (ACQUIRED)

736.5 GENU RECURVATUM (ACQUIRED)

736.6 OTHER ACQUIRED DEFORMITIES OF KNEE

736.70 - 736.76 UNSPECIFIED DEFORMITY OF ANKLE AND FOOT ACQUIRED - OTHER ACQUIRED CALCANEUS DEFORMITY

736.79 OTHER ACQUIRED DEFORMITIES OF ANKLE AND FOOT

736.81 UNEQUAL LEG LENGTH (ACQUIRED)

736.89 OTHER ACQUIRED DEFORMITY OF OTHER PARTS OF LIMB

737.0 ADOLESCENT POSTURAL KYPHOSIS

737.10 - 737.19 KYPHOSIS (ACQUIRED) (POSTURAL) - OTHER KYPHOSIS ACQUIRED

737.20 - 737.9 LORDOSIS (ACQUIRED) (POSTURAL) - UNSPECIFIED CURVATURE OF SPINE ASSOCIATED WITH OTHER CONDITIONS

754.1 CONGENITAL MUSCULOSKELETAL DEFORMITIES OF STERNOCLEIDOMASTOID MUSCLE

755.30 - 755.39 UNSPECIFIED REDUCTION DEFORMITY OF LOWER LIMB CONGENITAL - LONGITUDINAL DEFICIENCY PHALANGES COMPLETE OR PARTIAL

755.60 - 755.64

UNSPECIFIED CONGENITAL ANOMALY OF LOWER LIMB - CONGENITAL DEFORMITY OF KNEE (JOINT)

756.10 - 756.19 CONGENITAL ANOMALY OF SPINE UNSPECIFIED - OTHER CONGENITAL ANOMALIES OF SPINE

757.0 HEREDITARY EDEMA OF LEGS

780.4 DIZZINESS AND GIDDINESS

781.0 ABNORMAL INVOLUNTARY MOVEMENTS

781.2 ABNORMALITY OF GAIT

781.3 LACK OF COORDINATION

781.4 TRANSIENT PARALYSIS OF LIMB

781.8 NEUROLOGIC NEGLECT SYNDROME

781.92 ABNORMAL POSTURE

781.94 FACIAL WEAKNESS

781.99 OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS

782.0 DISTURBANCE OF SKIN SENSATION

783.3 FEEDING DIFFICULTIES AND MISMANAGEMENT

783.7 ADULT FAILURE TO THRIVE

784.69 OTHER SYMBOLIC DYSFUNCTION

785.4 GANGRENE

787.60 FULL INCONTINENCE OF FECES

787.61 INCOMPLETE DEFECATION

787.62 FECAL SMEARING

787.63 FECAL URGENCY

788.31 - 788.34 URGE INCONTINENCE - INCONTINENCE WITHOUT SENSORY AWARENESS

799.51 ATTENTION OR CONCENTRATION DEFICIT

799.54 PSYCHOMOTOR DEFICIT

799.55 FRONTAL LOBE AND EXECUTIVE FUNCTION DEFICIT

805.01 - 805.08 CLOSED FRACTURE OF FIRST CERVICAL VERTEBRA - CLOSED FRACTURE OF MULTIPLE CERVICAL VERTEBRAE

805.2 CLOSED FRACTURE OF DORSAL (THORACIC) VERTEBRA WITHOUT SPINAL CORD INJURY

805.4 CLOSED FRACTURE OF LUMBAR VERTEBRA WITHOUT SPINAL CORD INJURY

807.01 - 807.08 CLOSED FRACTURE OF ONE RIB - CLOSED FRACTURE OF EIGHT OR MORE RIBS

807.2 CLOSED FRACTURE OF STERNUM

808.0 CLOSED FRACTURE OF ACETABULUM

808.2 CLOSED FRACTURE OF PUBIS

808.41 - 808.43 CLOSED FRACTURE OF ILIUM - MULTIPLE CLOSED PELVIC FRACTURES WITH DISRUPTION OF PELVIC CIRCLE

808.44 MULTIPLE CLOSED PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE

808.49 CLOSED FRACTURE OF OTHER SPECIFIED PART OF PELVIS

808.54 MULTIPLE OPEN PELVIC FRACTURES WITHOUT DISRUPTION OF PELVIC CIRCLE

809.0 - 809.1 FRACTURE OF BONES OF TRUNK CLOSED - FRACTURE OF BONES OF TRUNK OPEN

810.01 - 810.03 CLOSED FRACTURE OF STERNAL END OF CLAVICLE - CLOSED FRACTURE OF ACROMIAL END OF CLAVICLE

811.01 - 811.09 CLOSED FRACTURE OF ACROMIAL PROCESS OF SCAPULA - CLOSED FRACTURE OF OTHER PART OF SCAPULA

812.01 - 812.59 FRACTURE OF SURGICAL NECK OF HUMERUS CLOSED - OTHER FRACTURE OF LOWER END OF HUMERUS OPEN

813.01 - 813.44 FRACTURE OF OLECRANON PROCESS OF ULNA CLOSED - FRACTURE OF LOWER END OF RADIUS WITH ULNA CLOSED

813.45 TORUS FRACTURE OF RADIUS (ALONE)

813.50 - 813.93 OPEN FRACTURE OF LOWER END OF FOREARM UNSPECIFIED - FRACTURE OF UNSPECIFIED PART OF RADIUS WITH ULNA OPEN

814.00 - 814.19 CLOSED FRACTURE OF CARPAL BONE UNSPECIFIED - OPEN FRACTURE OF OTHER BONE OF WRIST

815.00 - 815.19 CLOSED FRACTURE OF METACARPAL BONE(S) SITE UNSPECIFIED - OPEN FRACTURE OF MULTIPLE SITES OF METACARPUS

816.00 - 816.13 CLOSED FRACTURE OF PHALANX OR PHALANGES OF HAND UNSPECIFIED - OPEN FRACTURE OF MULTIPLE SITES OF PHALANX OR PHALANGES OF HAND

817.0 - 817.1 MULTIPLE CLOSED FRACTURES OF HAND BONES - MULTIPLE OPEN FRACTURES OF HAND BONES

818.0 - 818.1 ILL-DEFINED CLOSED FRACTURES OF UPPER LIMB - ILL-DEFINED OPEN FRACTURES OF UPPER LIMB

820.00 - 820.9 FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - FRACTURE OF UNSPECIFIED PART OF NECK OF FEMUR OPEN

821.00 - 821.39 FRACTURE OF UNSPECIFIED PART OF FEMUR CLOSED - OTHER FRACTURE OF LOWER END OF FEMUR OPEN

822.0 - 822.1 CLOSED FRACTURE OF PATELLA - OPEN FRACTURE OF PATELLA

823.00 - 823.92 CLOSED FRACTURE OF UPPER END OF TIBIA - OPEN FRACTURE OF UNSPECIFIED PART OF FIBULA WITH TIBIA

824.0 - 824.9 FRACTURE OF MEDIAL MALLEOLUS CLOSED - UNSPECIFIED FRACTURE OF ANKLE OPEN

825.0 - 825.39 FRACTURE OF CALCANEUS CLOSED - OTHER FRACTURES OF TARSAL AND METATARSAL BONES OPEN

826.0 - 826.1 CLOSED FRACTURE OF ONE OR MORE PHALANGES OF FOOT - OPEN FRACTURE OF ONE OR MORE PHALANGES OF FOOT

827.0 - 827.1 OTHER MULTIPLE AND ILL-DEFINED FRACTURES OF LOWER LIMB CLOSED - OTHER MULTIPLE AND ILL-DEFINED FRACTURES OF LOWER LIMB OPEN

831.01 - 831.09 CLOSED ANTERIOR DISLOCATION OF HUMERUS - CLOSED DISLOCATION OF OTHER SITE OF SHOULDER

832.01 - 832.09 CLOSED ANTERIOR DISLOCATION OF ELBOW - CLOSED DISLOCATION OF OTHER SITE OF ELBOW

832.2 NURSEMAID'S ELBOW

833.01 - 833.09 CLOSED DISLOCATION OF RADIOULNAR (JOINT) DISTAL - CLOSED DISLOCATION OF OTHER PART OF WRIST

834.01 - 834.02 CLOSED DISLOCATION OF METACARPOPHALANGEAL (JOINT) - CLOSED DISLOCATION OF INTERPHALANGEAL (JOINT) HAND

835.01 - 835.03 CLOSED POSTERIOR DISLOCATION OF HIP - OTHER CLOSED ANTERIOR DISLOCATION OF HIP

836.0 - 836.3 TEAR OF MEDIAL CARTILAGE OR MENISCUS OF KNEE CURRENT - DISLOCATION OF PATELLA CLOSED

836.51 - 836.59 ANTERIOR DISLOCATION OF TIBIA PROXIMAL END CLOSED - OTHER DISLOCATION OF KNEE CLOSED

837.0 CLOSED DISLOCATION OF ANKLE

838.01 - 838.09 CLOSED DISLOCATION OF TARSAL (BONE) JOINT UNSPECIFIED - CLOSED DISLOCATION OF OTHER PART OF FOOT

839.61 CLOSED DISLOCATION STERNUM

840.0 - 840.8 ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN - SPRAIN OF OTHER SPECIFIED SITES OF SHOULDER AND UPPER ARM

841.0 - 841.8 RADIAL COLLATERAL LIGAMENT SPRAIN - SPRAIN OF OTHER SPECIFIED SITES OF ELBOW AND FOREARM

841.9 SPRAIN OF UNSPECIFIED SITE OF ELBOW AND FOREARM

842.01 - 842.09 SPRAIN OF CARPAL (JOINT) OF WRIST - OTHER WRIST SPRAIN

842.11 - 842.19 SPRAIN OF CARPOMETACARPAL (JOINT) OF HAND - OTHER HAND SPRAIN

843.0 - 843.8 ILIOFEMORAL (LIGAMENT) SPRAIN - SPRAIN OF OTHER SPECIFIED SITES OF HIP AND THIGH

844.0 - 844.8 SPRAIN OF LATERAL COLLATERAL LIGAMENT OF KNEE - SPRAIN OF OTHER SPECIFIED SITES OF KNEE AND LEG

845.01 - 845.09 DELTOID (LIGAMENT) ANKLE SPRAIN - OTHER ANKLE SPRAIN

845.11 - 845.19TARSOMETATARSAL (JOINT) (LIGAMENT) SPRAIN - OTHER FOOT SPRAIN

846.0 - 846.8 LUMBOSACRAL (JOINT) (LIGAMENT) SPRAIN - OTHER SPECIFIED SITES OF SACROILIAC REGION SPRAIN

847.0 - 847.4 NECK SPRAIN - SPRAIN OF COCCYX

848.41 STERNOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN

848.42 CHONDROSTERNAL (JOINT) SPRAIN

848.5 PELVIC SPRAIN

880.00 - 880.09 OPEN WOUND OF SHOULDER REGION WITHOUT COMPLICATION - OPEN WOUND OF MULTIPLE SITES OF SHOULDER AND UPPER ARM WITHOUT COMPLICATION

880.10 - 880.19 OPEN WOUND OF SHOULDER REGION COMPLICATED - OPEN WOUND OF MULTIPLE SITES OF SHOULDER AND UPPER ARM COMPLICATED

880.20 - 880.29 OPEN WOUND OF SHOULDER REGION WITH TENDON INVOLVEMENT - OPEN WOUND OF MULTIPLE SITES OF SHOULDER AND UPPER ARM WITH TENDON INVOLVEMENT

881.00 - 881.22 OPEN WOUND OF FOREARM WITHOUT COMPLICATION - OPEN WOUND OF WRIST WITH TENDON INVOLVEMENT

882.0 - 882.2 OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITHOUT COMPLICATION - OPEN WOUND OF HAND EXCEPT FINGERS ALONE WITH TENDON INVOLVEMENT

883.0 - 883.2 OPEN WOUND OF FINGERS WITHOUT COMPLICATION - OPEN WOUND OF FINGERS WITH TENDON INVOLVEMENT

884.0 - 884.2 MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITHOUT COMPLICATION - MULTIPLE AND UNSPECIFIED OPEN WOUND OF UPPER LIMB WITH TENDON INVOLVEMENT

885.0 - 885.1 TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) COMPLICATED

886.0 - 886.1 TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) COMPLICATED

887.0 - 887.7 TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) UNILATERAL BELOW ELBOW WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

890.0 - 890.2 OPEN WOUND OF HIP AND THIGH WITHOUT COMPLICATION - OPEN WOUND OF HIP AND THIGH WITH TENDON INVOLVEMENT

891.0 - 891.2 OPEN WOUND OF KNEE LEG (EXCEPT THIGH) AND ANKLE WITHOUT COMPLICATION - OPEN WOUND OF KNEE LEG (EXCEPT THIGH) AND ANKLE WITH TENDON INVOLVEMENT

892.0 - 892.2 OPEN WOUND OF FOOT EXCEPT TOE(S) ALONE WITHOUT COMPLICATION - OPEN WOUND OF FOOT EXCEPT TOE(S) ALONE WITH TENDON INVOLVEMENT

893.0 - 893.2 OPEN WOUND OF TOE(S) WITHOUT COMPLICATION - OPEN WOUND OF TOE(S) WITH TENDON INVOLVEMENT

894.0 MULTIPLE AND UNSPECIFIED OPEN WOUND OF LOWER LIMB WITHOUT COMPLICATION

894.1 MULTIPLE AND UNSPECIFIED OPEN WOUND OF LOWER LIMB COMPLICATED

894.2 MULTIPLE AND UNSPECIFIED OPEN WOUND OF LOWER LIMB WITH TENDON INVOLVEMENT

895.0 - 895.1 TRAUMATIC AMPUTATION OF TOE(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF TOE(S) (COMPLETE) (PARTIAL) COMPLICATED

896.0 - 896.3 TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) UNILATERAL WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) BILATERAL COMPLICATED

897.0 - 897.7 TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL BELOW KNEE WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED

905.1 - 905.9 LATE EFFECT OF FRACTURE OF SPINE AND TRUNK WITHOUT SPINAL CORD LESION - LATE EFFECT OF TRAUMATIC AMPUTATION

906.0 LATE EFFECT OF OPEN WOUND OF HEAD NECK AND TRUNK

906.1 - 906.9 LATE EFFECT OF OPEN WOUND OF EXTREMITIES WITHOUT TENDON INJURY - LATE EFFECT OF BURN OF UNSPECIFIED SITE

908.6 LATE EFFECT OF CERTAIN COMPLICATIONS OF TRAUMA

909.2 LATE EFFECT OF RADIATION

909.3 LATE EFFECT OF COMPLICATIONS OF SURGICAL AND MEDICAL CARE

941.21 - 941.29 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF EAR (ANY PART) - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK

941.31 - 941.39 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF EAR (ANY PART) - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK

942.21 - 942.29 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF BREAST - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF OTHER AND MULTIPLE SITES OF TRUNK

942.31 - 942.39 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF BREAST - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF OTHER AND MULTIPLE SITES OF TRUNK

943.21 - 943.29 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FOREARM - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND

943.31 - 943.39 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOREARM - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND

944.21 - 944.28 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF WRIST(S) AND HAND(S)

944.31 - 944.38 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF SINGLE DIGIT (FINGER (NAIL)) OTHER THAN THUMB - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF WRIST(S) AND HAND(S)

945.21 - 945.29 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF TOE(S) (NAIL) - BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SITES OF LOWER LIMB(S)

945.31 - 945.39 FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF TOE(S) (NAIL) - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF LOWER LIMB(S)

946.2 - 946.3 BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF MULTIPLE SPECIFIED SITES - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SPECIFIED SITES

958.6 VOLKMANN'S ISCHEMIC CONTRACTURE

958.91 TRAUMATIC COMPARTMENT SYNDROME OF UPPER EXTREMITY

958.92 TRAUMATIC COMPARTMENT SYNDROME OF LOWER EXTREMITY

996.77 - 996.78 OTHER COMPLICATIONS DUE TO INTERNAL JOINT PROSTHESIS - OTHER COMPLICATIONS DUE TO OTHER INTERNAL ORTHOPEDIC DEVICE IMPLANT AND GRAFT

996.91 - 996.93 COMPLICATIONS OF REATTACHED FOREARM - COMPLICATIONS OF REATTACHED FINGER(S)

996.95 COMPLICATION OF REATTACHED FOOT AND TOE(S)

996.99 COMPLICATION OF OTHER SPECIFIED REATTACHED BODY PART

997.61 - 997.62 NEUROMA OF AMPUTATION STUMP - INFECTION (CHRONIC) OF AMPUTATION STUMP

998.59 OTHER POSTOPERATIVE INFECTION

 

V15.88 HISTORY OF FALL

V43.61 - V43.69 SHOULDER JOINT REPLACEMENT - OTHER JOINT REPLACEMENT

V43.7 LIMB REPLACED BY OTHER MEANS

V48.2 - V48.5 MECHANICAL AND MOTOR PROBLEMS WITH HEAD - SENSORY PROBLEM WITH NECK AND TRUNK

V49.1 - V49.3 MECHANICAL PROBLEMS WITH LIMBS - SENSORY PROBLEMS WITH LIMBS

V49.4 - V49.5 DISFIGUREMENTS OF LIMBS - OTHER PROBLEMS OF LIMBS

V49.61 - V49.67 THUMB AMPUTATION STATUS - SHOULDER AMPUTATION STATUS

V49.71 - V49.77 GREAT TOE AMPUTATION STATUS - HIP AMPUTATION STATUS

V52.0 FITTING AND ADJUSTMENT OF ARTIFICIAL ARM (COMPLETE) (PARTIAL)

V52.1 FITTING AND ADJUSTMENT OF ARTIFICIAL LEG (COMPLETE) (PARTIAL)

V52.8 FITTING AND ADJUSTMENT OF OTHER SPECIFIED PROSTHETIC DEVICE

V53.7 FITTING AND ADJUSTMENT OF ORTHOPEDIC DEVICES

V53.8 FITTING AND ADJUSTMENT OF WHEELCHAIR

V53.90 FITTING AND ADJUSTMENT OF UNSPECIFIED DEVICE

V54.01 - V54.29 ENCOUNTER FOR REMOVAL OF INTERNAL FIXATION DEVICE - AFTERCARE FOR HEALING PATHOLOGIC FRACTURE OF OTHER BONE

V57.81 CARE INVOLVING ORTHOTIC TRAINING

V58.30 - V58.31 ENCOUNTER FOR CHANGE OR REMOVAL OF NONSURGICAL WOUND DRESSING - ENCOUNTER FOR CHANGE OR REMOVAL OF SURGICAL WOUND DRESSING

V58.42 AFTERCARE FOLLOWING SURGERY FOR NEOPLASM

V58.49 OTHER SPECIFIED AFTERCARE FOLLOWING SURGERY

V88.21 ACQUIRED ABSENCE OF HIP JOINT

V88.22 ACQUIRED ABSENCE OF KNEE JOINT

V88.29 ACQUIRED ABSENCE OF OTHER JOINT

 

 

Documentations Requirements

 

• Documentation supporting the medical necessity should be legible, maintained in the patient's medical record, and must be made available to the A/B MAC upon request.

• The plan of treatment written by the patient’s physician after any needed consultation with the qualified physical therapist and signed by the physician.

o This must be in the patient’s medical record and made available to the A/B MAC upon request.

• When documenting family member/caregiver training and education, the documentation should include the person(s) being trained and the effectiveness of the training and education.

o The training and education should be an adjunct to the active therapy with the patient.

• OASIS data should support the medical necessity of the services documented in the medical records.

o For therapy services the OASIS MO2200 should be filled out completely and filed with the State Repository.

o An updated and completed OASIS for the billing period should be on file with the State Repository and in the patient’s medical records to be made available to the A/B MAC upon request.

• The progress note for services should reflect:

o An ongoing reassessment of the patient's response to treatment

o Progress toward predicted goals

o Clinical rationale for continued skilled treatment

o Recommended changes to the plan of treatment

o Services provided at the time of treatment

 

• Evaluation/Reevaluations

o The physician and/or physical therapist's evaluation/re-evaluation assess the area for which physical therapy treatment is being planned. It must be completed prior to beginning therapy. Evaluations must contain the following information:

 Reason for referral

 Diagnosis/condition being treated

 Past level of function (be specific)

 Evaluations must contain physical and cognitive baseline data necessary for assessing rehabilitation potential and measuring progress.

 Current level of function

 Objective measurements such as strength, ROM, pain, ADL level, or edema

 Treatment techniques/modalities selected for treating current illness or injury

 Limitations which may influence the length of treatment

 Short and long term goals stated in objective measurable terms, and their expected date of accomplishment

 Frequency and duration of therapy

 Re-assessments must be performed at least every 30 days by a qualified physical therapist.

 The 30 day clock begins with the first therapy’s visit/assessment/measurement/ documentation (of the physical therapy).

 

• Plan of Treatment

o Services are to be furnished according to a written plan of treatment determined by the physician after any needed consultations with the qualified physical therapist and signed and dated by the physician after an appropriate assessment (evaluation) of the condition (illness or injury) is completed.

 The plan of treatment must be completed before active therapy begins.

 The plan of treatment must be signed by the referring or attending physician prior to billing the service to Medicare.

 The written plan of treatment may not be altered by an physical therapist.

 *Electronic signatures are acceptable if the proper documentation is submitted to the J11 MAC.

 However, stamped dates are not allowed.

o The written plan of care must contain the following elements:

 Diagnosis being treated and the specific problems identified that are to be addressed

 Treatment techniques/modalities or procedures being used for specific problem to attain the stated goals

 Specific functional goals for therapy in objective measurable terms (patient/caregiver maybe included or taken into consideration)

 Amount, frequency, and duration of therapeutic services

 Rehabilitation potential - therapists/physician's expectation of the patient's ability to meet the goals at initiation of treatment (patient and, when appropriate, caregiver goals may be incorporated)

 

• Treatment Note/Progress Notes

o A treatment note should be written for each visit using objective measurements and functional accomplishments.

 It should contain the objective status of the patient, a description of the services performed, the patient's response to the services and the relation toward the treatment goals.

o The treatment note should document any treatment variations with the associated rationale.

o The treatment notes should be written using objective measurements and functional accomplishments. Use statements which demonstrate the patient's response to the therapy such as:

 "Able to perform exercises as prescribed for 15 reps"

 "Able to safely transfer from bed to toilet with standby assistance"

 "Can now abduct shoulder 120 degrees"

 "Able to don a pull over shirt with minimal assistance"

o Avoid terms such as:

 "Doing well"

 "Improving"

 "Less pain"

 "Increased range of motion"

 "Increased strength"

 "Tolerated treatment well"

 

• Certification/Re-certification

o The certifying physician must document that he or she had a face-to-face encounter with the patient.

 The encounter must occur no more than 90 days prior to the home health start of care date or within 30 days after the start of care.

o Certifications and re-certifications by the physician, must be on file and available to the J11 MAC when the request for payment is forwarded.

o Certifications are required upon initiation of therapy and at least every 60 days thereafter for Home Health.

o The referring/attending physician establishes or reviews the plan of treatment and makes the necessary certifications must sign and date all certifications/re-certifications.

o Documentation should indicate the prognosis for potential restoration of function in a reasonable and generally predictable period of time, or the need to establish a safe and effective maintenance program.

 

Sources of Information and Basis for Decision

 

Birrer, R (1994). Sports Medicine for the Primary Care Physician (2nd ed.). Boca Raton: CRC Press

 

DeLisa, J and Gans, B (Eds.). (1993). Rehabilitation Medicine: Principles and Practice. Philadelphia: J.B. Lippincott Company

 

Kottke, F and Lehmann, J (Eds.). (1990). Krusen’s Handbook of Physical Medicine and Rehabilitation (4th ed). Philadelphia: W.B. Saunders Company

 

American Physical Therapy Association. Guide to Physical Therapy Practice, 1997 (Revised April 1999)

 

Studenski, S, Duncan, P, Maino, J: Principles of Rehabilitation in Older Patients in Principles of Geriatric Medicine and Gerontology, Hazzard WR, Blass JP, Ettinger WH et al (eds); The McGraw Hill Companies, Inc., 1999.

 

Local Coverage Determination (LCD) for HOME HEALTH - PHYSICAL THERAPY (L31542)