Although there is an overlap in services provided by physical and occupational therapists, this policy addresses only physical therapy (PT).
PT services are part of a constellation of rehabilitative services designed to improve or restore physical functioning, as well as, to prevent injury, impairments, activity limitations, participation restrictions and disability following disease, injury or loss of a body part. Impairments, activity limitations and disabilities are addressed by the examination, evaluation and development of a plan of care (POC) that may include implementation of therapeutic interventions tailored to the specific needs of the individual patient to achieve specific goals and outcomes. The specific interventions that may be utilized are therapeutic exercises to strengthen muscles, maintain or restore motion, integumentary repair and protection techniques, physical agents and mechanical modalities, such as heat, cold, electrotherapeutic modalities, ultrasound (US) and hydrotherapy, manual therapy and functional training or retraining an individual to perform the activities of daily living (ADLs).
All PT services must be performed by or under the supervision of a qualified physical therapist.
For the purposes of this Local Coverage Determination (LCD), the descriptions/definitions of supervision are those given in 42 CFR §410.32(b)(3).
Qualified Physical Therapist: An individual who is licensed as a physical therapist and meets the practice requirements in the state where they are practicing.
For outpatient settings, references to “physicians” throughout this policy include nonphysician practitioners (NPPs), such as nurse practitioners, clinical nurse specialists and physician assistants. Such NPPs may certify, order and establish the POC for services by physical therapists as authorized by state law.
A qualified physical therapist, for program coverage purposes, is defined as an individual who is licensed as a physical therapist and meets the practice requirements in the state where they are practicing. Physiatrists, physicians or NPPs, and qualified physical therapists have the knowledge, training, and experience required to evaluate and, as necessary, re-evaluate a patient’s level of function, and determine whether a PT program could reasonably be expected to improve, restore or compensate for lost function. Where appropriate, the physical therapist can recommend to the physician or NPP a POC. While the skills of a qualified physical therapist are required to evaluate the patient’s level of function and develop a POC, implementation of the plan may also be carried out by a qualified physical therapy assistant (PTA) functioning under the general supervision of the qualified physical therapist.
Some services must be provided by a licensed therapist and may not be performed by a PTA such services include:
- Making clinical judgements or decisions
- Developing, managing or furnishing skilled maintenance programs
- Supervising other clinicians or taking responsibility for the service rendered
- Acting outside of the directions and supervision of a treating therapist in accordance with state laws
Restorative/Rehabilitative therapy:
In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services.
Maintenance therapy:
A maintenance program is a program designed to maintain or to slow deterioration as described in the CMS Internet-Only Manual Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, §220 and §220.2 and must meet these criteria to be considered reasonable and necessary.
GENERAL PT GUIDELINES
1. PT services are covered services provided the services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed physical therapist or under his/her supervision. Services normally considered a routine part of nursing care are not covered as PT (i.e., turning patients to prevent pressure injuries, walking a patient in the hallway postoperatively or ambulation without gait training).
2. Covered PT must be furnished while the individual is or was under the care of a physician. Services must relate directly and specifically to a written plan of treatment regimen established by the physician or NPP after any necessary consultation with the qualified physical therapist, or by the physical therapist providing the services and must be reasonable and necessary to the treatment of the individual's illness or injury.
3. In order for the plan of treatment to be covered, it must address a condition for which PT is an accepted method of treatment as defined by standards of medical practice. Also, the plan of treatment must be for a condition that is expected to improve significantly within a reasonable and generally predictable period of time or establishes a safe and effective maintenance program. If at any point in the treatment of an illness it is determined that the treatment is not rehabilitative or does not legitimately require the services of a qualified professional for management of a maintenance program, the services will no longer be considered reasonable and necessary and are excluded from coverage.
4. PT is only covered when it is rendered under a written plan of treatment established by the physician, NPP or the qualified physical therapist, to address specific therapeutic goals for which modalities and procedures are planned out specifically in terms of type, frequency and duration. The physician or NPP should periodically review the plan of treatment.
5. The physician or NPP and/or therapist must document the patient's functional limitations in terms that are objective and measurable.
SPECIFIC PROCEDURE AND MODALITY GUIDELINES
Computerized Dynamic Posturography
Computerized dynamic posturography is a "quantitative method for assessing balance functioning under various simulated tasks. Protocols are designed to test the sensory, motor and biomechanical components of balance individually and in concert." Computerized dynamic posturography "may assist with lesion localization, identifying adaptive strategies and functional capabilities."
*Note: Results of computerized dynamic posturography must be used in determining the patient centered POC.
Wound Care Selective
a) Debridement:
Debridement is indicated whenever necrotic tissue is present on a documented open wound. Debridement may also be indicated in cases of abnormal wound repair.
b) Conservative Sharp Debridement:
Conservative sharp debridement is a minor procedure that requires no anesthesia and is performed on an outpatient basis. Scalpel, scissors, and forceps may be used and only clearly identified devitalized tissue is removed. Generally, there is no specific bleeding associated with this procedure.
Wound(s) Care Non-Selective Debridement and Negative Pressure Wound Therapy
a) Enzymatic Debridement:
Debridement with topical enzymes is used when necrotic substances to be removed from a wound are protein, fibrin and collagen. The manufacturer's product insert contains indications, contraindications, precautions, dosage, and administration. It would be the clinician's responsibility to comply with the product insert/guidelines.
b) Autolytic Debridement:
This type of debridement is indicated where manageable amounts of necrotic tissue are present, and there is no infection. Autolytic debridement occurs when the enzymes that are naturally found in wound fluids are sequestered under synthetic dressings. Autolytic debridement is contraindicated for wounds that contain infection.
c) Mechanical Debridement:
Wet-to-moist dressings may be used with wounds that have a high percentage of necrotic tissue. Wet-to-moist dressings should be used cautiously as maceration of surrounding tissue may hinder healing.
Hydrotherapy and wound irrigation are also forms of mechanical debridement used to remove necrotic tissue. They also should be used cautiously, as maceration of surrounding tissue may hinder healing.
d) Negative Pressure Wound Therapy:
Negative Pressure Wound Therapy is a non-invasive treatment by which controlled localized negative pressure is delivered to a wide variety of acute, sub-acute, and chronic wounds. Negative Pressure Wound Therapy should be used cautiously as maceration of surrounding tissue may hinder healing.
Fabrication/Application of Casts, Splints and Strapping
Fabrication and application of casts, splints, and strapping (e.g., the use of elastic wraps, heavy cloth, adhesive tape) will be considered reasonable and necessary if used to support weak or ineffective joints/muscles, reduce/correct joint limitations/deformities and/or protect body parts from injury, thus enhancing the performance of tasks or movements. The casts, splints and strapping are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of patient needs and social/culture environments.
BODY AND UPPER EXTREMITY CASTS
Application of long arm cast
May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures and/or other deformities involving soft tissue.
Application of short arm cast
May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.
Application of hand and lower forearm cast
May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.
SPLINTS
Application of long arm splint
May be indicated for the shoulder and/or elbow in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.
Application of short arm splint
May be indicated for the forearm, wrist and/or hand in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.
Application of finger splint
May be indicated for the finger in the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures or other deformities involving soft tissue.
STRAPPING-ANY AGE
Strapping of thorax
May be indicated for the thoracic spine, lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Strapping of low back
May be indicated for the lumbar spine, rib cage or abdominal musculature in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Strapping of shoulder (e.g., Velpeau)
May be indicated for any portion of the shoulder girdle complex, or rib cage in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Strapping of elbow or wrist
May be indicated for the elbow or wrist when there is involvement of the humerus, forearm, wrist or hand in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissue.
Strapping of hand or finger
May be indicated when there is involvement of the hand or finger(s) in the treatment of contusions, dislocations, fractures, sprain/strains, post-op conditions, neuromuscular conditions, edema, scar management, contractures or other deformities involving soft tissue.
LOWER EXTREMITY CASTS
Application of long leg cast
May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.
Application of short leg cast
May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.
Application of rigid leg cast
May be indicated for recent amputees or patients with lower extremity ulcers.
SPLINTS
Application of long leg splint
May be indicated when there is involvement of the femur, patella, tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.
Application of short leg splint
May be indicated when there is involvement of the tibia, fibula, ankle or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, contractures or other deformities involving soft tissue.
STRAPPING-ANY AGE
Strapping of hip
May be indicated when there is involvement of the lower back, abdomen or hip in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Strapping of knee
May be indicated when there is involvement of the thigh, knee, or lower leg in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Strapping of ankle and/or foot
May be indicated when there is involvement of the lower leg, ankle and/or foot in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Strapping of toes
May be indicated when there is involvement of any of the toes in the treatment of contusions, dislocations, fractures, sprains/strains, post-op conditions, neuromuscular conditions, contractures or other deformities involving soft tissue.
Application of unna boot
A dressing for ulcers resulting from venous insufficiency, consisting of a paste made from gelatin zinc oxide and glycerin, which is applied to the leg, then covered with a spiral bandage, this in turn being given a coat of the paste. The process is repeated until satisfactory rigidity is attained.
Biofeedback training any method and biofeedback training perineal muscles, anorectal or urethral sphincter including EMG and/or manometry
The coverage criteria and definition of biofeedback therapy is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 1, §30.1 and §30.1.1.
"Biofeedback is a tool utilized by physical therapists to assist with muscle training. This includes facilitation of muscles that are demonstrating suboptimal performance as well as relaxation of muscles that may be inhibiting coordinated movement. Biofeedback can be visual or auditory."
Muscle testing, manual
Manual testing of muscle groups for strength are based on grading scales.
Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk
Every muscle of at least 1 extremity would need to be tested, with documentation of why such a thorough assessment was warranted.
Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side
Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands or including hands
The measurement of muscle performance using manual muscle testing only.
Range of Motion (ROM) Measurements
Determination of ROM using a tape measure, flexible ruler, electronic device or goniometer.
Every joint of an extremity would need to be tested, with documentation of why such a thorough assessment was warranted.
PT Evaluation
Evaluation is a comprehensive service that requires professional skills to make clinical judgments about conditions for which services are indicated based on objective measurements and subjective evaluations of patient performance and functional abilities. Evaluation is warranted, e.g., for a new diagnosis or when a condition is treated in a new setting. These evaluative judgments are essential to development of the POC, including goals and the selection of interventions. The time spent in evaluation does not count as treatment time.
1. The initial examination has the following components:
a. The patient history to include prior level of function
b. Relevant systems reviews
c. Tests and measures
d. Current functional status (abilities and deficits)
2. Factors that influence the complexity of the examination and evaluation process include the clinical findings, extent of loss of function, social considerations, and the patient's overall physical function and health status. Thus, the evaluation reflects the chronicity or severity of the current problem, the possibility of multi-site or multi-system involvement, the presence of preexisting systemic conditions or diseases, and the stability of the condition. Physical therapists also consider the level of the current impairments and the probability of prolonged impairment, functional limitation, disability, the living environment, and the social supports.
3. Initial evaluations or re-evaluations may be determined reasonable and necessary even when the evaluation determines that skilled rehabilitation is not required if the patient's condition showed a need for an evaluation, or even if the goals established by the plan of treatment are not realized.
4. Re-evaluation is periodically indicated during an episode of care when the professional assessment indicates a significant improvement or decline in the patient's condition or functional status. Some regulations and state practice acts require re-evaluation at specific intervals. A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals, and/or treatment or terminating services.
5. A re-evaluation may be appropriate prior to a planned discharge for the purposes of determining whether goals have been met, or for the use of the physician or the treatment setting at which treatment will be continued.
MAINTENANCE PROGRAMS
A maintenance program is a program intended to maintain function or slow the decline in function. Coverage of skilled rehabilitation services is contingent upon a beneficiary's need for skilled care. When a program to maintain or reduce decline in functional status requires the skills of a licensed therapist to be performed safely and effectively, provision of skilled services for the execution of that therapy program is covered. The skilled need must come from the nature of the service being rendered and the patient's unique circumstance. The provision of therapy services by skilled personnel does not in itself make the service one that requires skilled care.
Hot or Cold Packs Therapy
Hot or cold packs are used primarily in conjunction with therapeutic procedures to provide analgesia, relieve muscle spasm and reduce inflammation and edema. Typically, cold packs are used for acute, painful conditions, and hot packs are used for subacute or chronic painful conditions.
Mechanical Traction Therapy
1. Traction is generally limited to the cervical or lumbar spine with the hope of relieving pain in or originating from those areas.
2. Specific indications for the use of mechanical traction include:
a. Cervical and/or lumbar radiculopathy
b. Back disorders, such as disc herniation, lumbago, and sciatica
Vasopneumatic Device Therapy
1. The use of vasopneumatic devices may be considered reasonable and necessary for the application of pressure to an extremity for the purpose of reducing edema.
2. Specific indications for the use of vasopneumatic devices include:
a. Reduction of edema after acute injury
b. Lymphedema of an extremity
c. Education and training on the use of vasopneumatic devices for home use
Note: Further treatment on the use of vasopneumatic devices by physical therapists, after the education and training visits, is usually not reasonable and necessary. Generally, education and training can be completed in 3 visits.
Paraffin Bath Therapy
1. Paraffin bath, also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands, and feet.
2. Heat treatments of this type do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.
Whirlpool Therapy/Hubbard Tank
1. Heat treatments of this type and whirlpool baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures, or other complications. Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.
2. Whirlpool bath and Hubbard Tanks are the most common forms of hydrotherapy. The use of whirlpool is considered reasonable and necessary when used as part of a plan directed at facilitating the healing of an open wound (e.g., burns).
3. Specific indications for the use of whirlpools include the following:
a. The patient having a documented open wound which is draining, has a foul odor, or evidence of necrotic tissue
b. The patient having a documented need for wound debridement/bandage removal
c. Exfoliative skin impairments
Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders (Dry Whirlpool)
The coverage criteria and definition of fluidized therapy dry heat (dry whirlpool) are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.8.
Diathermy Treatment
Diathermy coverage criteria and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 2, §150.5 and Part 4, §240.3.
Infrared Therapy Devices
Noncoverage of Infrared Therapy Devices is described in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.6.
Ultraviolet Therapy
The application of ultraviolet therapy is considered reasonable and necessary for the patient requiring the application of a drying heat. The specific indications for this therapy are as follows:
a. A patient having an open wound; minimal erythema
b. Severe psoriasis limiting ROM
Electrical Stimulation Therapy
"Visual, verbal and/or manual contact "(i.e., constant attendance) when 1-on-1 instruction is required for subsequent home use of a Transcutaneous Electrical Nerve Stimulation (TENS) unit.
TENS is not reasonable and necessary for the treatment of Chronic Low Back Pain (CLBP) under §1862(a)(1)(A) of the Social Security Act.
Electrical Stimulation (ES) Therapy-Unattended
Electrical stimulation therapy and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.1.
Electromagnetic Therapy
Electromagnetic therapy criteria and definition are found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, §270.1.
Iontophoresis Application
1. Iontophoresis is a process in which electrically charged molecules or atoms (i.e., ions) are driven into tissue with an electrical field. Voltage provides the driving force. Parameters such as, drug polarity and electrophoretic mobility must be known in order to be able to assess whether iontophoresis can deliver therapeutic concentrations of a medication at sites below the skin.
2. The application of iontophoresis is considered reasonable and necessary for the topical delivery of medications into a specific area of the body.
3. Specific indications for the use of iontophoresis application include:
a. The patient having tendonitis or calcific tendonitis
b. The patient having bursitis
c. The patient having adhesive capsulitis
d. The patient having hyperhidrosis
e. Thick adhesive scar(s)
Contrast Baths
1. Contrast baths are a special form of therapeutic heat and cold that can be applied to distal extremities. The effectiveness of contrast baths is thought to be due to reflex hyperemia produced by the alternating exposure to heat and cold. Although a variety of applications are possible, contrast baths often are used in treatment to decrease edema and inflammation.
2. The use of contrast baths is considered reasonable and necessary to desensitize patients to pain by reflex hyperemia produced by the alternating exposure to heat and cold.
3. Specific indications for the use of contrast baths include:
a. The patient having rheumatoid arthritis or other inflammatory arthritis
b. The patient having reflex sympathetic dystrophy
c. The patient having a sprain or strain resulting from an acute injury
4. Heat treatments of this type and contrast baths do not ordinarily require the skills of a qualified physical therapist. However, in a particular case, the skills, knowledge and judgment of a qualified physical therapist might be required in such treatments or baths, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fractures or other complications. Also, if such treatments are given prior to but as an integral part of a skilled PT procedure, they would be considered part of the PT service.
US
1. Therapeutic US is a deep heating modality that produces a sound wave of 0.8 to 3.0 MHz. In the human body, US has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone can receive an even greater dosage of US, as much as 30% more. Because of the increased extensibility US produces in tissues of high collagen content, combined with the close proximity of joint capsules, tendons, and ligaments to cortical bone where they receive a more intense irradiation, it is an ideal modality for increasing mobility in those tissues with restricted ROM.
2. The application of US is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and the increase of muscle, tendon and ligament flexibility.
3. Specific indications for the use of US application include:
a. The patient having tightened structures limiting joint motion that require an increase in extensibility
b. The patient having symptomatic soft tissue calcification
c. The patient having neuromas
Note: US application is not considered to be reasonable and necessary for the treatment of asthma, bronchitis or any other pulmonary condition.
GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES
1. Therapeutic procedures are procedures that attempt to reduce impairments and improve function through the application of clinical skills and/or services.
2. Use of these procedures requires that these services be rendered under the supervision of a physical therapist.
3. Therapeutic exercises and neuromuscular reeducation are examples of therapeutic interventions. The expected goals documented in the written plan of treatment, effected by the use of each of these procedures, will help define whether these procedures are reasonable and necessary. Therefore, since any 1 or a combination of more than 1 of these procedures may be used in a written plan of treatment, documentation must support the use of each procedure as it relates to a specific therapeutic goal.
4. Services provided concurrently by a physical therapist and occupational therapist may be covered, if separate and distinct goals are documented in the written plan of treatment.
5. Require 1-on-1 direct patient contact, unless otherwise stated.
Therapeutic Exercises
1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively participating (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening, continuous passive motion).
2. Therapeutic exercise may address impairments of exercise tolerance due to cardiopulmonary impairments. Therapeutic exercise with an individualized physical conditioning and exercise program using proper breathing techniques can be considered for a patient with activity limitations secondary to cardiopulmonary impairments.
3. Therapeutic exercise is considered reasonable and necessary if at least 1 of the following conditions is present and documented:
a. The patient having weakness, contracture, stiffness secondary to spasm, spasticity, decreased joint ROM, gait problem, balance and/or coordination deficits, abnormal posture, muscle imbalance
b. The patient needing to improve mobility, flexibility, strengthening, coordination, control of extremities, dexterity, ROM, or endurance as part of ADLs training, or reeducation
4. Documentation for therapeutic exercise typically includes objective loss of joint motion, strength, and/or mobility (e.g., degrees of motion, strength grades, levels of assistance).
Neuromuscular Reeducation
1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, Biomechanical Ankle Platform [BAP’s] boards, and desensitization techniques).
2. Neuromuscular reeducation may be considered reasonable and necessary for impairments, which affect the body’s neuromuscular system (e.g., poor static or dynamic sitting/standing balance, loss of gross and fine motor coordination, tilt table or standing table, hypo/hypertonicity) and improvement of motor control and motor learning.
Aquatic Therapy with Therapeutic Exercises
"Aquatic therapy describes therapeutic exercises performed in a water-based environment. The properties and temperature of the water facilitate movement, particularly for muscles that are compromised due to injury, surgery, or disease (e.g., polio, rheumatoid arthritis, multiple sclerosis, joint arthroplasty)." It is important for the physical therapist to document the need for exercises performed in a water-environment vs land-based exercises. There should be a plan for transitioning from water-based exercises to land-based exercise.
1. This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and necessary for a loss or restriction of joint motion, strength, or mobility (e.g., degrees or motion, strength grades, levels of assistance).
2. Aquatic therapy with therapeutic exercise may be considered reasonable and necessary in the treatment of the following conditions:
a. The patient having pain, joint stiffness or muscle spasms resulting from rheumatoid arthritis
b. The patient having had a cast removed or recent surgery and requiring mobilization of limbs
c. The patient having paraparesis or hemiparesis
d. The patient having had a recent amputation
e. The patient recovering from a paralytic condition
f. The patient requiring limb mobilization after a head trauma
g. The patient having the inability to tolerate exercise for rehabilitation under gravity-based weight bearing
h. The patient having fibromyalgia
Gait Training
1. This procedure may be reasonable and necessary for training patients whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.
2. Specific indications for gait training include:
a. The patient having suffered a cerebral vascular accident resulting in impairment in the ability to ambulate, now stabilized and ready to begin rehabilitation
b. The patient having recently suffered a musculoskeletal trauma requiring gait reeducation
c. The patient having a chronic, progressively debilitating condition, for which safe ambulation has recently become a concern
d. The patient having had an injury or condition that requires instruction in the use of a walker, crutches, or cane
e. The patient having been fitted with a brace/lower limb prosthesis/orthosis and requires instruction in ambulation
f. The patient having a condition that requires retraining in stairs/steps or chair transfer in addition to general ambulation
3. Gait evaluation and training furnished to a patient whose ability to walk has been impaired by neurological, muscular or skeletal abnormality require the skills of a qualified physical therapist and constitute skilled PT and are considered reasonable and necessary, if they can be expected to materially improve or maintain the patient's ability to walk or prevent or slow further deterioration of the patient’s ability to walk. Gait evaluation and training which is furnished to a patient whose ability to walk has been impaired by a condition other than a neurological, muscular, or skeletal abnormality would, nevertheless, be covered where PT is reasonable and necessary to restore or maintain function or to prevent or slow further deterioration.
Massage Therapy
1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment, as well as, a treatment tool.
2. Massage therapy, including effleurage, pétrissage, and/or tapotement (stroking, compression, percussion) may be considered reasonable and necessary if at least 1 of the following conditions is present and documented:
a. The patient having paralyzed musculature contributing to impaired circulation
b. The patient having sensitivity of tissues to pressure
c. The patient having tight muscles resulting in shortening and/or spasticity of affective muscles
d. The patient having abnormal adherence of tissue to surrounding tissue
e. The patient requiring relaxation in preparation for neuromuscular reeducation or therapeutic exercise
f. The patient having contractures and decreased ROM
3. In most cases, postural drainage and pulmonary exercises can be carried out safely and effectively by nursing personnel. To be considered for payment, the physical therapist must identify the intervention that is best suited for the patient, taking into consideration the patient’s condition and any contraindications that may be present. As there can be an overlap of skills between disciplines, i.e., respiratory therapy, skilled nursing and PT, the documentation must clearly support the need for the intervention to be provided by the physical therapist.
Manual Therapy
1. Joint Mobilization (Peripheral or Spinal)
This procedure may be considered reasonable and necessary if restricted joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.
2. Soft Tissue Mobilization
This procedure involves the application of skilled manual therapy techniques (active or passive) to soft tissues in order to effect changes in the soft tissues, articular structures, neural or vascular systems. Examples are facilitation of fluid exchange, restoration of movement in acutely edematous muscles, or stretching of shortened muscular or connective tissue.
Soft tissue mobilization can be considered reasonable and necessary if at least 1 of the following conditions is present and documented:
a. The patient having restricted joint or soft tissue motion in an extremity, neck or trunk
b. Treatment being a necessary adjunct to other PT interventions
3. Manipulation
This procedure may be considered reasonable and necessary for treatment of painful spasm or restricted motion of soft tissues. It may also be used as an adjunct to other therapeutic procedures.
4. Manual Lymphatic Drainage/Complex Decongestive Therapy
The goal of this type of therapy is to reduce lymphedema by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain the reduction after therapy is complete. This therapy involves intensive treatment to reduce the size by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program.
a. It is expected that during these sessions, education is being provided to the patient and/or caregiver on the correct application of the compression bandage.
b. It is also expected that after the completion of the therapy, the patient and/or caregiver can perform these activities without supervision.
Group Therapeutic Procedures
A group for the purpose of performing group therapy will be defined as:
a. Two or more patients per therapist receiving active therapy but not 1-on-1 treatment, and
b. The patients may be performing the same exercise or a different exercise, but the physical therapist is instructing all the patients in the group.
Orthotic Training
1. This procedure may be considered reasonable and necessary, if there is an indication for education for the application of orthotics, and the functional use of the orthotic is present and documented.
2. Generally, orthotic training can be completed in 3 visits; however, for modification of the orthotic due to healing of tissues, change in edema, or impairment in skin integrity, additional visits may be required.
3. The medical record should document the distinct treatments rendered when orthotic training for a lower extremity is done during the same visit as gait training.
4. The patient is capable of being trained to use the particular device prescribed in an appropriate manner. In some cases, the patient may not be able to perform this function, but a responsible individual can be trained to apply the device.
Prosthetic Training
1. This procedure may be considered reasonable and necessary, if there is an indication for education in the application of the prosthetic, and the functional use of the prosthetic is present and documented.
2. The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training.
3. Periodic revisits beyond the third month would require documentation to support medical necessity.
Orthotic/Prosthetic Checkout
1. These assessments are reasonable and necessary for "established patients who have already received the orthotic or prosthetic device (permanent or temporary)."
2. These assessments may be reasonable and necessary when patients experience a loss of function directly related to the device (e.g., pain, skin breakdown, and falls).
3. These assessments may be reasonable and necessary for determining "the patient's response to wearing the device, determining whether the patient is donning/doffing the device correctly, determining the patient's need for padding, under wrap, or socks and determining the patient's tolerance to any dynamic forces being applied."
Therapeutic Activities
1. Therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques that involve movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a physical therapist and are designed to address a specific functional need of the patient. These dynamic activities must be part of an active written POC and be directed at a specific outcome.
2. In order for therapeutic activities to be covered, the following requirements must be met:
a. The patient having a condition for which therapeutic activities can reasonably be expected to restore or improve functioning
b. The patient’s condition being such that he/she is unable to perform therapeutic activities except under the direct supervision of a physician, NPP or physical therapist
c. There being a clear correlation between the type of exercise performed and the patient’s underlying medical condition for which the therapeutic activities were prescribed
Sensory Integrative Techniques
"Sensory integrative techniques are interventions generally intended for the pediatric and/or neurologically impaired populations. The focus of these activities is to train the sensory systems to modulate the vast array of incoming sensory stimuli. This is something that is normally performed without apparent effort. Once the patient/client learns to block the extrasensory 'noise,' the important sensory input can be processed, and a coordinated motor response can be generated."
Self-Care/Home Management Training
The coverage criteria of self-care management training is found in the CMS Internet-Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 3, §170.1.
"Self-care/home management training describes a group of interventions that focuses on ADL skills and compensatory activities needed to achieve independence" or adapt to an evolving deterioration in health and function. "These include activities such as dressing, bathing, food preparation, and cooking. The patient/client may require adaptive equipment and/or assistive technology in the home environment. This may include training the patient/client and/or caregiver in the use of the equipment."
Community/Work Reintegration
Services that are related solely to specific employment opportunities, work skills, or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by §1862(a)(1)(A) of the Social Security Act.
"Community/work reintegration training describes interventions intended to facilitate the patient's/client's ability to perform at work and in the community at large. Training could include accessing transportation systems and businesses, analysis of job site modification and work task analysis."
This training may be medically necessary when performed in conjunction with a patient's individual treatment plan aimed at improving or restoring specific community functions which were impaired by an identified illness or injury and when realistically expected outcomes are specified in the plan. This includes training in the use of assistive technology to assist with mobility, seating systems, and environmental control systems for use in the community. Services must be necessary for medical treatment of an illness or injury, rather than related solely to specific leisure or employment opportunities, work skills or work settings.
Work Hardening/Conditioning
"Work hardening and work conditioning are different interventions. Work hardening is an interdisciplinary program that is focused on tasks required for a specific job and uses real or simulated work activities to restore physical, behavioral, and vocational functions. Work hardening addresses productivity, safety, physical tolerances, and worker behavior. In contrast, work conditioning describes a work-related, intensive treatment program designed to restore strength, flexibility, and function so that the patient/client can return to work." These interventions are not covered.
Wheelchair Management Training
Wheelchair management "includes assessing if the patient/client needs a wheelchair, determining what kind of wheelchair is appropriate, including its size and components, measuring the patient/client to ensure proper fit, and fitting the patient/client into the chair once it is received. This includes the time associated with training the patient/client and/or caregiver in transfers in and out of the chair as well as propulsion on all surfaces. It is important for the therapist to provide instructions for safety so as not to risk skin breakdown or a fall."
1. This service trains the patient in functional activities that promote optimal safety, mobility and transfers. Patients who use wheelchairs for mobility may occasionally need skilled input on positioning to avoid pressure points, contractures, and other medical complications.
2. This procedure is reasonable and necessary only when it requires the skills of a physical therapist and is designed to address specific needs of the patient and must be part of an active written POC directed at a specific goal.
3. The patient and/or caregiver must have the capacity to learn from instructions.
4. Typically, 3 to 4 sessions should be sufficient to teach the patient and/or caregiver these skills.
5. Documentation should relate training to expected functional goals when providing wheelchair propulsion training.
Physical Performance Test or Measurement
This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions when such tests are needed to formulate or evaluate a specific written plan of treatment, or to determine a patient's functional capacity.
Assistive Technology Assessment
This assessment requires professional skill to gather data by observation and patient inquiry and may include limited objective testing and measurement to make clinical judgments regarding the patient's condition(s). Assessment determines, e.g., changes in the patient's status since the last visit and whether the planned procedure or service should be modified. Based on these assessment data, the professional may make judgment about progress toward goals and/or determine that a more complete evaluation or re-evaluation is indicated.
Canalith Repositioning Procedure(s) (e.g., Epley maneuver, Semont maneuver)
Canalith repositioning procedure describes a series of movements of the patient's body and head used for the treatment of benign paroxysmal positional vertigo (BPPV). The procedure is used to move displaced calcium crystal debris from the semicircular canals.
