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

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

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

NOTE:

Treatment plan submission to Highmark is not required in order to receive reimbursement for physical medicine, aquatic therapy or gait training services. However, the treatment plans for these services should be maintained in the patient's medical record.          

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

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

NOTE:

Supervised modalities, codes 97010-97028, are intended to be used only once during a patient encounter (visit) regardless of the number of areas treated. Also, time is not a factor in determining the use of the supervised modalities. Therefore, it is not appropriate to report multiple units of services with codes 97010-97028.  Only one unit of a specific modality is eligible per date of service.  Participating, preferred, and network providers cannot bill the member for the denied services.

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

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

Aquatic Therapy

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

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

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

Proper documentation should include:

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

NOTE:

If a provider cannot substantiate increased resistance experienced as the patient

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

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

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

Gait Training

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

Generally accepted indications for gait training include:

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

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

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

Vasopneumatic Compression (97016)

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

• Edema of the extremities (729.81, 757.0, 782.3)
• Hematoma of the leg (924.00, 924.10, 924.4, 924.5)
• Lymphedema of the arm (457.0 457.1) 
• Lymphedema of the leg (457.1, 757.0)
• Venous insufficiency or venous stasis disorder (459.81)

Conditions other than those listed above or those which indicate that an infection is present should be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

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

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

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

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

Infrared therapy, code 97026, will be denied as not medically necessary when reported for the following conditions:

Participating, preferred and network providers cannot bill the member for the denied service.

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 physical medicine or occupational therapy modalities:

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

Dry Hydro Massage (97799)

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

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

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

Equestrian/Hippotherapy (S8940)

Date Last Reviewed - 12/2006

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

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

Hands-Free Ultrasound

Date last Reviewed - 03/2007

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

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

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

Date Last Reviewed - 11/2005

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 Medicine or Athletic Training Evaluation

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

Consequently, when an evaluation and management service is reported in conjunction with a physical medicine evaluation or athletic training evaluation, the services should be combined under the appropriate code for the physical medicine evaluation or athletic training evaluation. A participating, preferred, or network provider cannot bill the member for the E&M service.

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

Maintenance Therapy

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

NOTE:

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

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

For information on a vasopneumatic devices, refer to Medical Policy Bulletin, E-7.

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

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

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 physical medicine 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
02/2004, Guidelines on physical therapy, occupational therapy and athletic training evaluations
02/2005, How to report maintenance manipulations
04/2005, Hippotherapy considered investigational
10/2005, Aquatic therapy reporting guidelines outlined
10/2005, Blue Shield to apply occupational therapy benefits to code 97530
02/2006, Hands-free ultrasound therapy considered investigational
04/2006, Report hands-free ultrasound with code 97799
06/2006, Application of a vasopneumatic device eligible for specific indications
10/2006, Use code 97799 to report dry hydro massage
02/2007, Reporting guidelines for supervised PM&R modalities explained
06/2007, Blue Shield limits coverage of eletromagnetic stimulation to treatment of chronic ulcers
06/2007, Infrared light therapy coverage indications outlined

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

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

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

CMS National Coverage Determination: Infrared Therapy Devices (CAG-0029IN), Oct. 4, 2006

Magnetotherapy: Historical Background with a Stimulating Future, Critical Reviews in Physical and Rehabilitation Medicine, Vol. 16, No. 2, 2004

Pulsed magnetic field therapy in refractory neuropathic pain secondary to peripheral neuropathy: electrodiagnostic parameters - pilot study, Neurorehabil Neural Repair, Vol 18, No.1, March 2004

Effect of pulsed magnetic field therapy on the level of fatigue in patients with multiple sclerosis - a randomized controlled trial, Multiple Sclerosis, Vol. 11, No.3, June 2005

The Effect of Monochromatic Infrared Energy on Sensation in Patients with Diabetic Peripheral Neuropathy, Diabetes Care, Vol. 28, No. 12, December 2005