Physical medicine and rehabilitation (PM&R) is a covered service when performed with the expectation of restoring the patient's level of function which has been lost or reduced by injury or illness.

PM&R treatment should be provided in accordance with an ongoing, written treatment plan. The treatment plan should include:

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

The treatment plan should be updated as the patient's condition changes.

Outpatient PM&R should be paid in accordance with the following guidelines:

1. A typical PM&R session usually consists of up to one hour of rehabilitative therapy or up to three PM&R modalities/procedures performed on the same date of service.
2. Payment may be made for up to 15 outpatient PM&R sessions per calendar year (January-December).
3. Claims requesting outpatient PM&R sessions in excess of 15 sessions are subject to review for the purpose of establishing medical necessity. Providers are required to submit the patient's treatment plan for review. Sessions in excess of 15 without an approved treatment plan will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service. Additional supportive documentation from the provider requesting additional sessions could include the provider's pertinent evaluations (exam findings), progress notes, and opinions about the patient's need for continued therapy services. In addition, the medical history, as it relates to outpatient PM&R, must include the date of onset and/or exacerbation of the illness or injury. Any history of treatments from a previous provider is also necessary for patients who have transferred to a new provider for additional treatment. The limitation addressed in this paragraph does not apply to inpatient PM&R services.

Coverage for Physical Medicine and Rehabilitation is determined according to individual or group customer benefits.

Aquatic Therapy

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

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

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

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

Proper documentation should also include:

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

NOTE:

If a provider cannot substantiate increased resistance experienced as the patient exercises in water, the session will be considered as endurance or conditioning rather than progressive resistance exercises (PRE) to strengthen.

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

Procedure code 97113 represents aquatic therapy with therapeutic exercise.

Payment for procedure code 97113 includes whirlpool (97022) and/or Hubbard tank (97036). Separate payment will not be made for 97022 or 97036 in addition to 97113 for a single patient encounter.

Gait Training

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

Generally accepted indications for gait training include:

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

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

Procedure code 97116 should not be used to report orthotics or prosthetics training. Orthotics training should be reported using procedure code 97504. Prosthetics training should be reported using procedure code 97520.

Vestibular Rehabilitation Therapy

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

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

• peripheral vestibular disorders {e.g., labyrinthitis (386.30-386.35), neuritis (386.12), benign paroxysmal positional vertigo (386.11), post vestibular surgical symptoms, and bilateral vestibular loss},
• mixed {peripheral (386.10-386.19) and central (386.2)} vestibular disorders, and
• central causes of vertigo {e.g., CVA (436), multiple sclerosis (340), and mild traumatic brain injury}

If none of these conditions are reported, a vestibular rehabilitation program is considered not medically necessary, and therefore, not covered. A participating, preferred, or network provider cannot bill the member for the denied services.

A vestibular rehabilitation program may include the following PM&R modalities:

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

Dry Hydro Massage

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

Dry hydro massage is considered not medically necessary.  A participating, preferred, or network provider cannot bill the member for the denied service.

Low-Level Laser Therapy (S8948)

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

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

Physical Therapy or Athletic Training Evaluation

Separate payment may not be made for a PM&R evaluation (97001-97002) or an athletic training evaluation (97005-97006), and another evaluation and management service on the same day by the same or an affiliated provider.

Muscle testing (95831-95834), range of motion testing (95851-95852), and physical performance testing (97750) are considered components of a PM&R evaluation (97001-97002) or an athletic training evaluation (97005-97006), and are not eligible for separate payment when billed on the same day as a PM&R evaluation or athletic training service.

Maintenance Therapy

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

NOTE:

For information on cognitive rehabilitation and sensory integration techniques, refer to Medical Policy Bulletin Y-2.

PM&R is covered whether provided by a doctor or a licensed physical therapist.

Major Medical

This policy applies to Major Medical except points 2 and 3 of the outpatient PM&R guidelines section.

Managed Care

This medical policy applies to Managed Care programs except, points number 2 and 3 of the outpatient PM&R guidelines section.

The submission of a treatment plan for the initial period of service is not required for managed care programs except for members age 12 and under. The initial period of service will cover up to 12 visits for medically necessary/appropriate care. However, Healthcare Management Services (HMS) must be contacted with the basic clinical and demographic information pertaining to the member to ensure that claims will process and pay correctly for initial period of service. A treatment plan must be submitted as soon as it is determined that a course of treatment will require more than the initial 12 visits.

HMO and POS

For HMO and coordinated POS programs, outpatient PM&R must be coordinated with the member's primary care physician. Therapy type and duration must be approved by the primary care physician and the Plan, prior to the member beginning outpatient PM&R.

Please note that POS members may self-refer for outpatient PM&R services.

When the member meets the medical necessity criteria detailed in this medical policy, please refer to the member's specific benefits schedule to determine and approve the duration of outpatient PM&R services.

PRN References

02/1993, Physical therapy reporting tips
05/1994, Physical therapy quick reference guide
06/1994, Outpatient physical therapy
01/1995, Physical therapy reporting tips
01/1995, Postoperative physical therapy
08/1995, Postoperative physical therapy
10/1996, Aquatic therapy
10/1996, Gait training
10/1996, Manipulation and physical therapy changes
10/1996, Therapy treatment plan
12/1996, Manipulation and physical therapy treatment plan: tips for completing form 3861
12/1996, Therapeutic activities - code 97530 - to remain physical therapy service
02/1997, Physical therapy quick reference guide
02/1998, New physical and occupational therapy coding guidelines adopted
06/2002, Manipulation and physical therapy reporting changes explained
08/2002, Highmark deletes routine maintenance therapy code
04/2003, Dry hydro massage
10/2003, Therapeutic neuromuscular education

Vestibular Rehabilitation of Patients with Vestibular Hypofunction or with Benign Paroxysmal Positional Vertigo, Current Opinions, Neurology, Volume 13, No. 1, 02/2000

Efficacy of Vestibular Rehabilitation, Otolaryngologic Clinics of North America, Volume 33, No. 3, 06/2000

Outcome Analysis of Individualized Vestibular Rehabilitation Protocols, The American Journal of Otology, Volume 21, No. 4, 07/2000