HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 

Medical Policy:
Y-1-057
Topic:
Physical Medicine
Section:
Therapy
Effective Date:
December 17, 2018
Issued Date:
December 17, 2018
Last Revision Date:
November 2018
Annual Review:
July 2016
 
 

Physical medicine and rehabilitation is a medical specialty concerned with diagnosis, evaluation, and management of persons with physical impairment and disability. This specialty involves diagnosis and treatment of patients with painful or functionally limiting conditions, the management of comorbidities and co-impairments.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

Coverage for physical medicine is determined according to individual or group customer benefits.

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.

Treatment plans must be maintained in the medical record, and made available upon request.

A typical session usually consists of up to one (1) hour of rehabilitative therapy which could include up to four (4) physical medicine modalities/procedures and/or units performed on the same date of service, per performing provider.

Reimbursement for physical therapy (PT)/occupational therapy (OT) visits involving any physical medicine procedures are limited as follows:

  • Up to four (4) codes/units in any combination per date of service per performing provider.
  • Payment will be based on the highest submitted and allowed physical medicine procedures.
    • Modalities- 97012-97039, G0283, S8950
    • Therapeutic procedures- 97110-97542
    • Tests and measurements 97750
    • Muscle range of motion (ROM) testing- 95831-95852
    • Orthotic management and prosthetic management- 97760- 97763

Services exceeding the limitation will be considered not medically necessary.

Duplicate therapy is considered not medically necessary.

95831 95832 95833 95834 95851 95852 95992 97012 97014 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97161 97162 97163 97164 97165 97166 97167 97168 97530 97533 97535 97537 97542 97750 97760 97761 97763 97799 G0283 S8940 S8948 S8950 S8990



Physical Medicine Evaluation
Evaluation and Management (E&M) service is considered an inherent part of a physical medicine evaluation. The E&M service is not eligible for separate payment when reported on the same day as a physical medicine evaluation.

When an Evaluation and Management service is reported in conjunction with a physical medicine evaluation the services should be combined under the appropriate code for the physical medicine evaluation.

Modifier "-25" may be reported with medical care (e.g. E/M visits, consultations) to identify it as significant and separately identifiable from the other service(s) provided on the same day. When modifier "-25" is reported, the patient’s medical records must clearly document that separately identifiable medical care was rendered.

Muscle testing, ROM testing, and physical performance testing are considered components of a physical medicine evaluation and are not eligible for separate payment when billed on the same date of service as a physical medicine evaluation.

Modifier "-59" may be reported with a non-E/M service, to identify it as distinct or independent from other non-E/M services performed on the same day.

97161 97162 97163 97164 97165 97166 97167 97168



Maintenance Therapy
Physical medicine services performed repetitively to maintain a level of function are not eligible for reimbursement unless the member has Habilitative services benefits.

A maintenance program consists of activities that preserve the patient's present level of function and prevent regression of that function. These service  would not involve complex physical medicine and rehabilitative procedures, nor would they require clinical judgment and skill for safety and effectiveness.

Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. Maintenance therapy should be reported under procedure code S8990 (physical or manipulative therapy performed for maintenance rather than restoration), and not eligible for reimbursement.

97110 97112 97113 97116 97124 97139 97140



Habilitative Therapy
Habilitative therapy services ordered by a professional provider to promote the restoration, maintenance or improvement in the level of function following disease, illness or injury. This also includes therapies to achieve functions or skills never acquired due to congenital and developmental anomalies.

Habilitative/Rehabilitative therapy services must be reported with the 96 or 97 modifiers in conjunction with the appropriate therapy code.

Habilitative therapy is not eligible for payment, unless the member has a habilitative benefit.

*Spinal manipulation is not considered a habilitative service.

97110 97112 97113 97116 97124 97139 97140



Supervised Modalities
Supervised modalities do not require direct one-on-one patient contact by the provider. These are not time-based codes.

97012 97014 97016 97018 97022 97024 97026 97028



Vasopneumatic Compression (97016)
Treatment is warranted for the following conditions:

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

Conditions other than those listed above or indicate that an infection is present will be denied as not medically necessary.

 Vasopneumatic compression 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.

97016



Infrared Therapy (97026)
The use of infrared and near-infrared light and heat, including monochromatic infrared energy, is considered not 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.

97026



Constant Attendance Modalities
Constant attendance modalities are those modalities that require direct one-on-one individual contact by the provider. Documentation must include the amount of time spent in providing all aspects of this service.

When two (2) constant attendance modalities are performed at the same time, using one device, the code representing the primary modality must be reported.

97032 97033 97034 97035 97036 97039



Aquatic Therapy
Aquatic therapy must be performed with the expectation of restoring an individuals 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 and is not eligible for payment.

A provider must have direct (one to one) patient contact when reporting aquatic therapy.       

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

Separate reimbursement will not be made for whirlpool or Hubbard tank in addition to aquatic therapy with therapeutic exercise for a single individual encounter.

97113 97034



Gait Training
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 codes 97760 and 97763.
  • Prosthetics training should be reported using procedure codes 97761 and 97763.
97116



Vestibular Rehabilitation Therapy
A vestibular rehabilitation program typically last 45 minutes per session and is prescribed 1-2 times per week. In general, individuals remain in the program 4-8 weeks.

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

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

If none of these conditions are reported, a vestibular rehabilitation program is considered not medically necessary.

S9476



Pennsylvania State Mandate (Act 62 – 2008) Autism Spectrum Disorders Coverage Mandate (ASD) Effective July 1, 2009
Act 62-2008 (Autism Spectrum Disorders Coverage Mandate) requires coverage for individuals who are under twenty-one (21) years of age for the diagnostic assessment and treatment of autism spectrum disorders.

Coverage is subject to a maximum benefit of forty thousand dollars ($40,000) per year, for policies issued or renewed in calendar year 2013. For policies that have renewal periods and benefit periods that differ, the new maximum benefit does not become effective until the subsequent benefit period. Coverage is not subject to any limits on the number of visits to an autism service provider for treatment of autism spectrum disorders. Coverage is subject to copayment, deductible and coinsurance provisions, as well as any other general exclusions or limitations set forth in the member’s contract.


 


Not Medically Necessary

  • Dry Hydro Massage

Experimental/Investigational and, therefore, non-covered

  • Electromagnetic Stimulation
  • Equestrian/Hippotherapy
  • Low-Intensity Pulsed Ultrasound (Hands-Free Ultrasound)
  • Horizontal Therapy
  • Low-Level Laser Therapy (Cold Laser Therapy)
  • Phonophoresis
97035 97799 S8948



Refer to medical policy E-45 Interferential Stimulator for additional information.

Refer to medical policy V-37 on Autism Spectrum Disorders for additional information

Refer to medical policy Y-2, Occupational Therapy (OT) for additional information.

Refer to medical policy Y-9, Manipulation Services for additional information.

Refer to medical policy Y-11 Manual Lymphedema Drainage Therapy for additional information.

Refer to medical policy Y-12 Urinary Incontinence Therapy for additional information.       

Refer to medical policy Y-21 Cognitive Rehabilitation for additional information.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.


Covered Diagnosis Codes for Procedure Code: 97016

I87.2

I87.8

I87.9

I89.0

I97.2

M79.81

M79.89

Q82.0

R60.0

R60.1

R60.9

S70.10XA

S70.11XA

S70.12XA

S80.10XA

S80.11XA

S80.12XA

 

 

 

 

 

Covered Diagnosis Codes for Procedure Code - 97116

F82

M21.371

M21.372

M21.379

M51.24

M51.25

M51.26

M51.27

S98.111A

S98.111D

S98.111S

S98.112A

S98.112D

S98.112S

S98.121A

S98.121D

S98.121S

S98.122A

S98.122D

S98.122S

S98.131A

S98.131D

S98.131S

S98.132A

S98.132D

S98.132S

S98.141A

S98.141D

S98.141S

S98.142A

S98.142D

S98.142S

S98.211A

S98.211D

S98.211S

S98.212A

S98.212D

S98.212S

S98.221S

S98.221D

S98.221S

S98.222A

S98.222D

S98.222S

Z96.641

Z96.642

Z96.643

Z96.649

Z96.651

Z96.652

Z96.653

Z96.659

Z96.661

Z96.662

Z96.669

 

 

Covered Diagnosis Codes for Procedure Code:  S9476

G35

H81.10

H81.11

H81.12

H81.13

H81.20

H81.21

H81.22

H81.23

H81.311

H81.312

H81.313

H81.319

H81.391

H81.392

H81.393

H81.399

H81.41

H81.42

H81.43

H83.01

H83.02

H83.03

H83.09

I63.30

I63.311

I63.312

I63.313

I63.321

I63.322

I63.323

I63.329

I63.331

I63.332

I63.333

I63.339

I63.341

I63.342

I63.343

I63.349

I63.411

I63.412

I63.413

I63.419

I63.421

I63.422

I63.423

I63.429

I63.431

I63.432

I63.433

I63.439

I63.441

I63.442

I63.443

I63.449

I97.81

I97.82

 

 

 

 

 



Place of Service: Inpatient/Outpatient

Physical medicine is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances including, but not limited to the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.



The policy position applies to all commercial lines of business



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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

    Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.





    Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

    Discrimination is Against the Law
    The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats, other formats)

  • Provides free language services to people whose primary language is not English, such as:
  • Qualified interpreters
  • Information written in other languages
  • If you need these services, contact the Civil Rights Coordinator.

    If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295 , TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.

    You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

    U.S. Department of Health and Human Services
    200 Independence Avenue, SW
    Room 509F, HHH Building
    Washington, D.C. 20201
    1-800-368-1019, 800-537-7697 (TDD)

    Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.