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Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

01-97000-01

Original Effective Date: 07/15/99

Reviewed: 08/25/16

Revised: 12/01/16

Subject: Physical Therapy (PT) and Occupational Therapy (OT)

Clinical View

 

This medical coverage guideline is not an authorization, certification, explanation of benefits, or a guarantee of payment, nor does it substitute for or constitute medical advice. All medical decisions are solely the responsibility of the patient and physician. Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered. This medical coverage guideline applies to all lines of business unless otherwise noted in the program exceptions section.

 

DESCRIPTION:

Physical therapy (PT) is a prescribed program of treatment consisting of specific therapeutic exercises and other interventions designed to restore or improve posture, ambulation, strength, endurance, balance, coordination, joint mobility, flexibility and ability to perform functional activities of daily living, and on alleviating pain. Treatment involves the use of the therapeutic properties of exercise, heat, cold, electricity, ultraviolet, and/or massage.

Occupational therapy (OT) is a prescribed program of treatment consisting of specific therapeutic and goal-directed activities to restore or improve skills needed to perform activities of daily living. Individual programs are designed to restore or improve the ability to conduct basic activities such as dressing, eating, personal hygiene, and mobility/transfers. OT is generally focused on therapeutic activities intended to restore or improve function to the shoulder, elbow, wrist or hand.

Therapeutic intervention may be passive or active. Passive intervention is defined as motion imparted to the body by another person or outside force, such as a joint being moved without using the muscles that ordinarily control the joint. Active intervention is defined as motion imparted to the body through voluntary participant contraction and relaxation of the controlling muscles. Passive interventions are often used during the acute phase of treatment, when the focus is on reducing pain and swelling. Active interventions are usually begun as pain and swelling subsides, when the focus is on restoring range of motion and function.

The American Medical Association (AMA) Current Procedural Terminology (CPT) manual defines a modality as "any physical agent applied to produce therapeutic changes to biologic tissue; includes but is not limited to thermal, acoustic, light, mechanical, or electric energy.” (AMA 2014)

POSITION STATEMENT:

 

Certificate of Medical Necessity

Submit a completed Certificate of Medical Necessity (CMN) along with your request to expedite the medical review process.

1. Click the link Physical Therapy (PT) and Occupational Therapy (OT) - Certificate of Medical Necessity (MS Word) to open the form.

2. Complete all fields on the form thoroughly.

3. Print and submit a copy of the form with your request.

Note: Florida Blue regularly updates CMNs. Ensure you are using the most current copy of a CMN before submitting to Florida Blue. For a complete list of available CMNs, visit the Certificates of Medical Necessity page.

NOTE: The following services are covered according to the member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to physical and occupational therapy services (see PROGRAM EXCEPTIONS).

*NOTE: For coverage of physical and occupational therapy for Autism Spectrum Disorders, please refer to MCG 01-97000-08, Treatment of Autism Spectrum disorders.

Physical or occupational therapy evaluation, re-evaluation, procedures, techniques, interventions and modalities meet the definition of medical necessity when ALL the conditions below are met:

The level of complexity or the member’s condition requires that the services be performed by or under the direct supervision of a qualified physical or occupational therapist, AND

The services meet accepted standards of practice, AND

The services are specific and effective treatment for the member’s condition, AND

The services are rendered in accordance with a physician directed treatment plan, AND

For continued therapy, the plan of care should be updated as the member’s condition changes and should be recertified by a physician at least every 90 days.

Prior to the initiation of physical or occupational therapy, a comprehensive evaluation of the member’s physical and functional potential is required. The initial physical or occupational therapy evaluation should be performed by a qualified provider of physical or occupational therapy services, and should include:

Specific statements regarding history and diagnosis, AND

Specific short-term and long-term goals with measurable objectives, AND

The specific techniques and/or exercises to be used in the treatment, AND

The frequency and duration of the treatment.

Physical and occupational therapy services meet the definition of medical necessity when performed to improve or restore physical functions in members who have a functional deficit that is associated with:

An illness or condition [e.g., cerebrovascular accident (stroke)]

An exacerbation of a chronic illness or condition

An injury or trauma

A surgical procedure

A congenital defect

Massage therapy (97124) and manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, and manual traction) (97140) performed by a licensed massage therapist, meets the definition of medical necessity when the following criteria are met:

• Documentation is provided indicating 97124 OR 97140 are specifically prescribed by the attending physician as medically necessary, AND

• The attending physician's prescription specifies the number of treatments.

See BILLING/CODING INFORMATION SECTION for the list of diagnoses NOT covered for Massage therapy (CPT code 97124).

NOTE: Massage therapy services are subject to the contract limitations applied to all other physical therapy services.

Aquatic therapy meets the definition of medical necessity when all criteria for physical or occupational therapy above are met, and the aquatic therapy does not duplicate therapy provided on land.

Manual lymph drainage (97140 or S8950), also known as complex decongestive physiotherapy OR complex lymphedema therapy, is a method for treating lymphedema by way of massage, exercise, and compression bandaging several times a day, usually for 4 – 6 weeks, in an effort to redirect lymph fluid back into circulation and reduce swelling in the affected extremity.

Manual lymph drainage therapy is eligible for coverage when the patient can be instructed in continuing the therapy at home or when there is a caregiver who can assist the patient in continuing home therapy. Initiation of therapy should be limited to one course or program per lifetime.

Physical performance tests and measurements (97750), (e.g., musculoskeletal, functional capacity) are eligible for coverage when rendered for the purpose of evaluating a patient's physical performance, determining function of one or more body areas or measuring any aspect of physical performance including functional capacity evaluations.

NOTE: Per CPT the use of code 97750 requires direct one-on-one patient contact as well as a separate written report.

Comprehensive computer-based motion analysis by video-taping and 3-D kinematics (gait analysis), (96000, 96001, 96002, 96003, 96004) is the quantitative laboratory assessment of human walking, and includes videotaped observation of the patient walking, as well as measurements of joint angles, step length, stride length, cadence, and cycle time. EMG, assessed during walking, measures timing and intensity of muscle contractions, allowing determination of whether a certain muscle’s activity is normal, out of phase, continuous, or clonic. A dedicated facility-based motion analysis laboratory uses a computer-based analysis of videotaping and 3D kinematics, tracking retroreflective markers along the body.

Comprehensive motion analysis (gait analysis) services meet the definition of medical necessity for the preoperative or postoperative evaluation of musculoskeletal function upon gait in patients diagnosed with cerebral palsy.

The use of computer-based motion analysis by video-taping and 3-D kinematics (gait analysis) for all other indications does not meet the definition of medical necessity.

The following physical therapy services do not meet the definition of medical necessity:

Non-skilled services: treatments that do not require the skills of a qualified provider, such as passive range of motion exercise which is not related to development, restoration or improvement of a specific function.

Duplicate therapy: if patient receives both physical and occupational therapy, the therapies should provide different treatments and not duplicate the same treatment. They must also have separate treatment plans and goals.

Maintenance programs: 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.

The following services are considered experimental or investigational due to the lack of scientific evidence of effects on health outcomes:

Electrodynography, which is a computerized diagnostic procedure that quantitatively measures and times weight bearing forces exerted in the feet and legs; may be associated with gait analysis (motion analysis)

Skeletal analysis systems (e.g., Metrecom Skeletal Analysis System to measure angular positions of bony structures)

Dry Hydrotherapy, performed unattended on a table or chair that contains an electrically powered massager device with rotating hydro-jets and the pressure of the water against the barrier provides the massage (also known as hydromassage, aquamassage, and water massage).

Unattended vibromassage therapy, performed unattended on a table or chair that uses low frequency vibrations to stimulate body cells into therapeutic states of relaxation and healing.

Augmented Soft-tissue Mobilization (ASTM), a non-invasive mobilization technique that uses hand-held tools (bone, stone, metal) along with a lubricant on the skin to scrape and mobilize fibrotic (scar) tissue resulting from chronic musculoskeletal disorders.

Kinesio taping, a method of taping which uses a fabric tape that is air permeable and water resistant and applies a constant pulling force to the skin over which it is applied; often used immediately following injury and during the rehabilitation process.

Dynamic Method of Kinetic Stimulation [(MEDEK therapy or Cuevas Medek Exercises (CME)]), a mode of physical therapy used to develop gross motor skills in infants and children with movement disorders due to neurological dysfunction; it uses the principle of anti-gravity extension.

Interactive metronome program, a therapy designed to improve concentration, focus and coordination, in which participants wear headphones and hear a fixed, repeating reference beat. They respond by pressing a hand or foot sensor to try to match the beat, while receiving visual and auditory feedback.

Hands-free ultrasound (low frequency sound, or infrasound), an ultrasound unit that allows the clinician to choose the mode of ultrasound delivery, using either a hand-held (manual) transducer or a hands-free device that pulses the ultrasound beam through the transducer.

Equestrian therapy (S8940), also known as horseback riding or hippotherapy, is an exercise thought to offer a person with a disability a means of physical activity that aids in improving balance, posture, coordination, the development of a positive attitude and a sense of accomplishment. It is often proposed for the treatment of autism spectrum disorders, multiple sclerosis, and cerebral palsy.

Hivamat therapy (deep oscillation therapy), utilizes an intermittent electrostatic field via a Hivamat machine; the theory is that electrostatic waves create a kneading effect deep within the damaged tissues (deeper than manual methods), restoring flexibility and blood supply to the affected area, and allowing previously untreatable injuries to be manipulated with a minimum of physical pressure.

BILLING/CODING INFORMATION:

ICD-10 Diagnosis Codes NOT Covered for Massage therapy (CPT Codes 97124): (Effective 10/01/15)

C50.011 – C50.929

Malignant neoplasm breast

C71.0-C71.9

Malignant neoplasm of brain

E08.628

Diabetes mellitus due to underlying condition with other skin complications

E09.628

Drug or chemical induced diabetes mellitus with other skin complications

F41.0 – F41.9

Anxiety and panic disorders

G20

Parkinson's disease

G21.0 – G21.9

Secondary parkinsonism

G43.901 – G43.919

Migraine, unspecified

G44.001 – G44.89

Headache

G89.21 – G89.29

Chronic pain

G89.0 – G89.4

Chronic pain syndrome

G93.3

Postviral fatigue syndrome

L44.8-L44.9

Papulosquamous disorder

L45

Papulosquamous disorders in diseases classified elsewhere

L90.5

Scar conditions and fibrosis of skin

L92.1

Necrobiosis lipoidica, not elsewhere classified

L92.3

Foreign body granuloma of the skin and subcutaneous tissue

L94.2

Calcinosis cutis

L94.4

Gottron's papules

L98.8-L98.9

Other specified and unspecified disorders of the skin and subcutaneous tissue

L99

Other disorders of skin and subcutaneous tissue in diseases classified elsewhere

M05.00 – M05.9

Rheumatoid arthritis

M06.00 – M06.9

Rheumatoid arthritis without rheumatoid factor

M08.00 – M08.99

Juvenile rheumatoid arthritis

M12.00 – M12.9

Chronic postrheumatic arthropathy

M15.0 – M15.9

Polyosteoarthritis

M16.0 – M16.9

Unilateral primary osteoarthritis

M17.0 – M17.9

Bilateral primary osteoarthritis, knee

M18.0 – M18.9

Unilateral primary osteoarthritis of first carpometacarpal joint

M19.0 – M19.93

Osteoarthritis

M32.0 – M32.9

Systemic lupus erythematosus with organ or system involvement

M33.00 – M33.99

Dermatopolymyositis

M34.0 – M34.9

Systemic sclerosis [scleroderma]

M35.00 – M35.09

Sicca syndrome

M35.1 – M35.9

Systemic involvement of connective tissue

M36.0, M36.8

Dermato(poly)myositis in neoplastic disease

M41.40 – M41.57

Neuromuscular scoliosis

M43.8X1 – M43.9

Other specified deforming dorsopathies

M46.40 – M46.49

Discitis

M48.01 – M48.03

Spinal stenosis, occipito-atlanto-axial region; cervical region; cervicothoracic region

M50.00 – M50.93

Cervical disc disorder with myelopathy

M51.34 – M51.37

Other thoracic, thoracolumbar and lumbosacral intervertebral disc degeneration

M51.9

Unspecified thoracic, thoracolumbar and lumbosacral intervertebral disc disorder

M54.10

Radiculopathy, site unspecified

M54.18

Radiculopathy, sacral and sacrococcygeal region

M54.30 – M54.42

Lumbago and sciatica

M60.80 – M60.9

Myositis

M79.0 – M79.2

Rheumatism; neuralgia and neuritis

M79.1, M79.2,
M79.7

Myalgia; neuralgia; fibromyalgia

M96.1

Postlaminectomy syndrome

M99.20 – M99.71

Stenosis of neural canal

N20.1 – N20.9

Calculus of ureter

N22

Calculus of urinary tract in diseases classified elsewhere

R07.82 – R07.89

Intercostal and other chest pain

R20.0 – R20.9

Disturbances of skin sensation

R52

Pain, unspecified

R53.0 – R53.1

Malaise and fatigue

R53.81 – R53.83

Other malaise and fatigue

Z33.1

Pregnant state, incidental

Procedure code 97039 may be used to report an unlisted modality. Medical documentation is required for medical review for 97039. The following information may be required documentation to support medical necessity: physician history and physical, physician treatment plan, physical therapy treatment plan, plan of treatment, description of the procedure, and the time, effort, and equipment necessary to provide the service.

REIMBURSEMENT INFORMATION:

NOTE: Refer to member’s/subscriber’s contract benefits. Member’s/subscriber’s contract benefits may have limitations, exclusion, or criteria applicable to physical therapy services (see program exceptions). Services may be subject to medical review of documentation (e.g., physician history and physical, physician progress notes, plan of treatment (narrative), physical therapy treatment plan, plan of treatment, progress note and attainment of goals, reason to continue and justification) for determination of medical necessity. The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment (narrative), physical therapy treatment plan, plan of treatment, progress note and attainment of goals, reason to continue and justification.

LOINC Codes:

DOCUMENTATION TABLE

LOINC CODES

LOINC TIME FRAME MODIFIER CODE

LOINC TIME FRAME MODIFIER CODES NARRATIVE

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy initial assessment

18735-1

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physical therapy progress note

11508-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan, Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage Products:

The following National Coverage Determinations (NCD) were reviewed on the last guideline reviewed date: Manipulation (150.1), Diathermy Treatment (150.5), Fluidized Therapy Dry Heat for Certain Musculoskeletal Disorders (150.8) and Heat Treatment, Including the Use of Diathermy and Ultra-Sound for Pulmonary Conditions (240.3), located at cms.gov.

The following Local Coverage Determinations (LCDs) were reviewed on the last guideline reviewed date: Therapy and Rehabilitation Services (L29289) and Comprehensive Motion Analysis Studies (L29116) located at fcso.com.

Coverage mandated by the state of Florida: refer to member’s/subscriber’s contract benefits.

Coverage for speech therapy, occupational therapy, physical therapy, and applied behavior analysis is mandated by Florida statute for some contracts.

Florida Statute 627.6686 [Coverage for individuals with autism spectrum disorder required; exception] and Florida Statute 641.31098 [Coverage for individuals with developmental disabilities]:

A health maintenance contract shall provide coverage to an eligible individual for treatment of autism spectrum disorder and Down syndrome through speech therapy, occupational therapy, physical therapy, and applied behavior analysis.

When the mandate applies:

Children must be under 18 years of age, or still in high school, and have been diagnosed as having autism spectrum disorder at 8 years of age or younger, OR

Children must be under 18 years of age, or still in high school, and have been diagnosed as having Down syndrome.

DEFINITIONS:

Aquatic therapy: therapeutic physical therapy exercises which takes place in or on water, most likely in a swimming pool. This involves the therapist doing manipulation, mobilization or manual stretching and strengthening in the water instead of on land. This type of therapy is often prescribed following intra-articular and ligament reconstruction in the knee, as well as for walking reeducation, strengthening leg muscles, enhancing joint range of motion, and rheumatic disease.

Condition: a disease, illness, ailment, injury, or pregnancy.

Habilitative services: health care services that are short-term and help a person to acquire or attain an age-appropriate bodily function necessary to participate in activities of daily living.

Rehabilitative services: health care services rendered for the purpose of restoring function lost due to illness, injury or surgical procedures.

RELATED GUIDELINES:

OTHER:

None applicable.

REFERENCES:

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  65. Van Ooijen MW, Roerdink M, Trekop M, Visschedijk J, Janssen TW, Beek PJ. Functional gait rehabilitation in elderly people following a fall-related hip fracture using a treadmill with visual context: design of a randomized controlled trial. BMC Geriatrics 2013, 13:34.
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COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/24/14.

GUIDELINE UPDATE INFORMATION:

07/15/99

Medical Coverage Guideline developed.

04/01/02

HCPCS coding update; S8945 added.

01/01/03

HCPCS coding update; E0761 added.

02/15/03

Review of guideline; no change in coverage statement.

04/01/03

HCPCS coding update; S8945 deleted.

04/15/03

Revision of guideline; G0283 added.

08/15/03

Revision of guideline consisting of addition of information on infrared and low level laser, addition of G0281 and addition of cross-reference for diathermy and ultrasound for wound healing.

01/01/04

Annual HCPCS coding update.

03/15/04

Review and revision of guideline; consisting of updated references and addition of cross-references for pelvic floor stimulation, TMJ dysfunction and electrical stimulation for wound healing.

07/01/04

2nd quarter HCPCS update; consisting of the addition of S8948.

03/15/05

Review and revision of guideline; consisting of updated references.

01/01/06

Annual HCPCS coding update consisting of the deletion of 97020, 97505 and 97520.

03/15/06

Review and revision of guideline consisting of updated references.

06/15/06

Revision of guideline consisting of the addition of investigational statements for DRS therapy and dry hydrotherapy.

10/15/07

Review and revision of guideline consisting of updated references and reformatted guideline.

09/15/08

Scheduled review; no change in position statement. Update references. Update related guidelines.

04/01/09

Unscheduled review; update position statement and reimbursement section. Add program exception for Florida Statute 627.6686 and Medicare program exception for Comprehensive Motion Analysis (Gait Analysis).

09/15/09

Update exception section for treatment of autism.

04/15/10

Annual review; no change in position statement. Updated description for physical tests and measurements CPT code 97750. References updated.

04/15/11

Revision; added ICD-9 & ICD-10 diagnosis codes related to massage therapy.

07/15/11

Revision; formatting changes.

08/15/11

Revision; added a statement to the Position Statement that the treatment plan must be recertified by the physician at least every 60 days.

07/15/12

Scheduled review. Revised MCG title, description section and position statement. Updated references.

07/15/13

Scheduled review. Added coverage statement for Interactive Metronome Program (E/I). Revised ICD9 and ICD10 coding sections. Updated Medicare Advantage program exception. Updated references.

04/15/14

Revised ICD9 and ICD10 coding for massage therapy.

08/15/14

Scheduled review. Revised position statement and definitions section. Updated references.

10/01/15

Revision; updated ICD10 coding section.

11/01/15

Revision: ICD-9 Codes deleted.

07/15/16

Revision: Updated Program Exceptions section and references.

09/15/16

Revision: updated Positon Statement section and Definitions section.

12/01/16

Program Exceptions section revised.

Date Printed: June 24, 2017: 11:33 AM