Clinical UM Guideline

 

Subject: Physical Therapy
Guideline #:  CG-REHAB-04 Publish Date:    04/25/2018
Status: Revised Last Review Date:    03/22/2018

Description

This document addresses physical therapy (PT) services, skilled services which may be delivered by a physical therapist or other health care professional acting within the scope of a professional license. Physical therapy is used for both rehabilitation and habilitation.

Rehabilitative services are intended to improve, adapt or restore functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality involving goals an individual can reach in a reasonable period of time. Benefits will end when treatment is no longer medically necessary and the individual stops progressing toward those goals.

Habilitative services are intended to maintain, develop or improve skills needed to perform activities of daily living (ADLs) or instrumental activities of daily living (IADLs) (see definitions) which have not (but normally would have) developed or which are at risk of being lost as a result of illness, injury, loss of a body part, or congenital abnormality. Examples include therapy for a child who is not walking at the expected age.

The terms “physical therapy” and “physiotherapy” are synonymous.

Note: The availability of rehabilitative and/or habilitative benefits for these services, state and federal mandates, and regulatory requirements should be verified prior to application of criteria listed below. Benefit plans may include a maximum allowable physical therapy benefit, either in duration of treatment or in number of visits. When the maximum allowable benefit is exhausted, coverage will no longer be provided even if the medical necessity criteria described below are met.

Note: Please see the following related documents for additional information:

Clinical Indications

Rehabilitative Services

Medically Necessary:

Rehabilitative physical therapy (PT) services are considered medically necessary when ALL the following criteria are met:

  1. The therapy is aimed at improving, adapting or restoring functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality; and
  2. The therapy is for conditions that require the unique knowledge, skills, and judgment of a physical therapist for education and training that is part of an active skilled plan of treatment; and
  3. There is an expectation that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time; and
    1. An individual’s function could not reasonably be expected to improve as the individual gradually resumes normal activities; and
    2. An individual’s expected restoration potential would be significant in relation to the extent and duration of the therapy service required to achieve such potential; and
    3. The therapy documentation objectively verifies progressive functional improvement over specific time frames; and
  4. The services are delivered by a qualified provider of physical therapy services (see definition); and
  5. The services require the judgment, knowledge, and skills of a qualified provider of physical therapy services due to the complexity and sophistication of the therapy and the medical condition of the individual.

Not Medically Necessary:

Maintenance (see definitions) therapy is considered not medically necessary as a rehabilitative service.

Rehabilitative PT services are considered not medically necessary if any of the following is determined:

  1. The therapy is not aimed at improving, adapting or restoring functions, which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality.
  2. The therapy is for conditions for which therapy would be considered routine educational, training, conditioning, or fitness. This includes treatments or activities that require only routine supervision.  
  3. The expectation does not exist that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time.
    1. If function could reasonably be expected to improve as the individual gradually resumes normal activities, then the therapy is considered not medically necessary.
    2. If an individual’s expected restoration potential would be insignificant in relation to the extent and duration of the therapy service required to achieve such potential, the therapy would be considered not medically necessary.
    3. The therapy documentation fails to objectively verify functional progress over a reasonable period of time.
  4. The physical modalities are not preparatory to other skilled treatment procedures.
  5. Treatments that do not generally require the skills of a qualified provider of PT services are considered not medically necessary. Examples include palliative massages, palliative Jacuzzi /whirlpools, hot or cold packs in the absence of complicating factors, general range of motion or exercise programs, maintenance therapy, repetitive gait or other activities that an individual can self-practice independently or with a caregiver, swimming and routine water aerobics programs, general fitness and training, and general public education/instruction sessions.
  6. Routine reevaluations not meeting the above criteria.
  7. Treatments that are not supported in peer-reviewed literature.

Duplicate rehabilitative therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline’s unique perspective on the individual’s impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

Habilitative Services

Medically Necessary:

Habilitative PT services are considered medically necessary when ALL the following criteria are met:

  1. The therapy is intended to maintain or develop skills needed to perform ADLs or IADLs which, as a result of illness (including developmental delay), injury, loss of a body part, or congenital abnormality, either:
    1. have not (but normally would have) developed; or
    2. are at risk of being lost; and
  2. The services are evidence-based and require the judgment, knowledge, and skills of a qualified provider of physical therapy services due to the complexity of the therapy and the medical condition of the individual; and
  3. There is the expectation that the therapy will assist development of normal function or maintain a normal level of function; and
  4. There is a written treatment plan documenting the short- and long-term goal(s) of treatment, frequency and duration of treatment (including an estimate of when the goals will be met), and what quantitative measures will be used to assess objectively the level of functioning; and
  5. An individual would either not be expected to develop the function or would be expected to permanently lose the function (not merely experience fluctuation in the function) without the habilitative service; if the undeveloped or impaired function is not the result of a loss of body part or injury, a physician experienced in the evaluation and management of the undeveloped or impaired function has confirmed that the function would either not be expected to develop or would be permanently lost without the habilitative service and concurs that the written treatment plan is likely to result in meaningful development of the function or prevention of loss of the function; and
  6. The therapy documentation objectively verifies that, at a minimum, functional status is developed or maintained; and
  7. The services are delivered by a qualified provider of physical therapy services (see definition).

Not Medically Necessary:

Habilitative PT services are considered not medically necessary if any of the following is determined:

  1. The therapy is not aimed at developing or maintaining functions, which would normally develop.
  2. The therapy is aimed at a function which would be permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality whether or not therapy was provided.
  3. The therapy is for conditions for which therapy would be considered routine educational, training, conditioning, or fitness. This includes treatments or activities that require only routine supervision.
  4. The expectation does not exist that the therapy will result in developing or maintaining the expected level of functioning within a reasonable and predictable period of time.
  5. The therapy documentation fails to objectively verify functional status is, at a minimum, maintained.
  6. The physical modalities are not preparatory to other skilled treatment procedures.
  7. Treatments that do not generally require the skills of a qualified provider of PT services, such as, palliative massages, palliative Jacuzzi /whirlpools, hot or cold packs in the absence of complicating factors, repetitive gait or other activities that an individual can self-practice independently or with a caregiver, swimming and routine water aerobics programs, general fitness and training, and general public education/instruction sessions.
  8. Routine reevaluations not meeting the above criteria.
  9. Treatments that are not supported in peer-reviewed literature.

Duplicate habilitative therapy is considered not medically necessary. When individuals receive physical, occupational, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline’s unique perspective on the individual’s impairments and functional deficits and not duplicate the same treatment. They must also have separate evaluations, treatment plans, and goals.

Other Treatment Modalities for Physical Therapy Services

Not Medically Necessary:

Physical therapy services are considered not medically necessary when the above criteria are not met, including but not limited to:

  1. Elastic therapeutic tape/taping (for example, Kinesio™ Tape);
  2. Massage therapy when provided in the absence of covered physical therapy services;
  3. Services for the purpose of enhancing athletic performance or for recreation;
  4. Treatments that are not supported in peer-reviewed literature.

Documentation

Evaluation
A comprehensive evaluation is essential to determine if PT services are medically necessary, gather baseline data, establish a treatment plan, and develop goals based on the data. The initial evaluation is usually completed in a single session. An evaluation is needed before implementing any PT treatment. Evaluation begins with the administration of appropriate and relevant assessments using standardized assessments and tools. The evaluation must include:

Treatment Sessions
A physical therapy session can vary from fifteen minutes to four hours per day; however, treatment sessions lasting more than one hour per day are rare in outpatient settings. Treatment sessions for more than one hour per day may be medically appropriate for inpatient acute settings, day treatment programs, and select outpatient situations, but must be supported in the treatment plan and based on an individual’s medical condition. A physical therapy session may include:

Documentation of treatment sessions must include:

Progress Reports
In order to reflect that continued PT services are medically necessary, intermittent progress reports must demonstrate that the individual is making functional progress. Progress reports should include at a minimum:

Reevaluation
A reevaluation is indicated when there are new clinical findings, a rapid change in the individual’s status, or failure to respond to physical therapy interventions. There are several routine reassessments that are not considered reevaluations. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries.

Reevaluation is a more comprehensive assessment that includes all the components of the initial evaluation, such as:

Providers of PT Services

The services are delivered by a qualified provider of physical therapy services acting within the scope of their license as regulated by the Federal and State governments. In addition to licensure, physical therapists must have passed the National Physical Therapy Examination (NPTE). Physical therapy assistants may provide services under the direction and supervision of a physical therapist. Benefits for services provided by these practitioners are dependent upon the member’s contract language.

Aides, athletic trainers, exercise physiologists, life skills trainers, and rehabilitation technicians do not meet the definition of a qualified practitioner regardless of the level of supervision. Aides and other nonqualified personnel as listed above are limited to non-skilled services such as preparing the individual, treatment area, equipment, or supplies; assisting a qualified therapist or assistant; and transporting individuals. They may not provide any direct treatments, modalities, or procedures.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT

 

90901

Biofeedback training by any modality [when done for medically necessary indications]

94667

Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function, initial demonstration and/or evaluation

94668

Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function; subsequent

97010-97028

Application of a modality to one or more areas (supervised) [includes codes 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028]

97032-97036

Application of a modality to one or more areas (constant attendance) [includes codes 97032, 97033, 97034, 97035, 97036]

97039

Unlisted modality [when not specified as a procedure that is considered investigational and not medically necessary]

97110-97124

Therapeutic procedure, one or more areas [includes codes 97110, 97112, 97113, 97116, 97124

97127

Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact

97139

Unlisted therapeutic procedure (specify)

97140

Manual therapy techniques (eg, mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes

97150

Therapeutic procedure(s), group (2 or more individuals)

97161-97163

Physical therapy evaluation [includes codes 97161, 97162, 97163]

97164

Re-evaluation of physical therapy established plan of care

97530

Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

97169-97172

Athletic training evaluation [includes codes 97169, 97170, 97171, 97172]

Note: Athletic training is considered not medically necessary for enhancing athletic performance or for recreation.

97533

Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes

97535

Self care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes

97537

Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes

97542

Wheelchair management (eg, assessment, fitting, training), each 15 minutes

97545-97546

Work hardening/conditioning

97597-97598

Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudates, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session

97602

Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

97750

Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes

97755

Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes

97760

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes

97761

Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetics(s) encounter, each 15 minutes

97763

Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

97799

Unlisted physical medicine/rehabilitation service or procedure [when not specified as a procedure that is considered investigational and not medically necessary]

 

 

HCPCS

 

G0151

Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes

G0157

Services performed by a qualified physical therapist assistant in the home health or hospice setting, each 15 minutes

G0159

Services performed by a qualified physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes

G0281

Electrical stimulation, (unattended), to one or more areas, for chronic stage III and stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care

G0282

Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G0281

G0283

Electrical stimulation (unattended), to one or more areas for indication(s) other then wound care, as part of a therapy plan of care

G0295

Electromagnetic therapy, to one or more areas, for wound care other than described in G0329 or for other uses

G0329

Electromagnetic therapy, to one or more areas for chronic stage III and stage IV pressure ulcers, arterial ulcers, and diabetic ulcers and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care

G0515

Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

S8950

Complex lymphedema therapy

S8990

Physical or manipulative therapy performed for maintenance rather than restoration

S9117

Back school, per visit

S9131

Physical therapy, in the home, per diem

 

 

 

Note: The following CPT informational modifiers  may be used with the above procedure codes:

96

Habilitative Services

97

Rehabilitative Services

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

Physical therapy may be used for either rehabilitation services or habilitation services as described above. Other uses of physical therapy services not supported by peer reviewed literature, including but are not limited to, services for the purpose of enhancing athletic performance or for recreation and elastic therapeutic tape/taping.

Elastic therapeutic tape/taping (also known as Kinesio tape/taping) is an air permeable and water resistant tape capable of stretching up to 140% of its original length. The tape is designed to provide a constant pulling force over the area applied. Elastic taping has been studied as a therapy for acute whiplash injury, knee pain, low back pain, treatment and prevention of sports injuries, and enhancement of functional motor skills. (Added, 2016; Campolo, 2013; Gonzalez-Iglesias, 2009; Halseth, 2004; Williams, 2012; Yasukawa, 2006). Currently there is insufficient evidence to support the use of Kinesio taping over other treatment approaches to reduce pain or disability. Further study is needed before clinical effectiveness and benefit can be established.

The American College of Occupational and Environmental Medicine (ACOEM) practice guideline on evaluation and management of common health problems and functional recovery in workers (Hegmann, 2007) found insufficient evidence to support the use of “taping or Kinesio taping for acute, subacute, or chronic LBP, radicular pain syndromes or other back-related conditions.”

Definitions

Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.

Developmental delay: A condition that occurs when a child is not developing or achieving skills by the expected time frame. Developmental delay can occur in one or many areas -for example, thinking (cognitive), gross or fine motor, language or social skills (American Academy of Pediatrics, 2006).

Instrumental activities of daily living (IADLs): Activities related to independent living and include preparing meals, managing money, shopping, doing housework and using a telephone; IADLs do not involve personal care activities.

Maintenance treatments: Services intended to preserve the individual’s present level range, strength, coordination, balance, pain, activity, function, etc. and prevent regression of the same parameters. 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.

Qualified provider of physical therapy services: One who is licensed where required and performs within the scope of licensure.

References

Peer Reviewed Publications:

  1. Added MA, Costa LO, de Freitas DG, Fukuda TY, Monteiro RL, Salomão EC, de Medeiros 2 FC, Costa Lda C. Kinesio Taping Does Not Provide Additional Benefits in Patients 3 With Chronic Low Back Pain Who Receive Exercise and Manual Therapy: A 4 Randomized Controlled Trial. J Orthop Sports Phys Ther. 2016; 46(7):506-513.
  2. Fu TC, Wong AM, Pei YC, et al. Effect of Kinesio taping on muscle strength in athletes-a pilot study. J Sci Med Sport. 2008;11(2):198-201.
  3. González-Iglesias J, Fernández-de-Las-Peñas C, Cleland JA, et al. Short-term effects of cervical kinesio taping on pain and cervical range of motion in patients with acute whiplash injury: A randomized clinical trial. J Orthop Sports Phys Ther. 2009; 39(7):515-521.
  4. Kalichman L, Vered E, Volchek L. Relieving symptoms of meralgia paresthetica using Kinesio taping: A pilot study. Arch Phys Med Rehabil. 2010;91(7):1137-1139.
  5. Thelen MD, Dauber JA, Stoneman PD. The clinical efficacy of kinesio tape for shoulder pain: A randomized, double-blinded, clinical trial. J Orthop Sports Phys Ther. 2008; 38(7):389-395.
  6. Williams S, Whatman C, Hume PA, Sheerin K. Kinesio taping in treatment and prevention of sports injuries: a meta-analysis of the evidence for its effectiveness. Sports Med. 2012; 42(2):153-164.
  7. Yasukawa A, Patel P, Sisung C. Pilot study: Investigating the effects of Kinesio Taping in an acute pediatric rehabilitation setting. Am J Occup Ther. 2006; 60(1):104-110.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American Academy of Pediatrics. Council on Children with Disabilities; Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee; Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006; 118(1):405-420.
  2. American Physical Therapy Association. Access to, admission to, and patient/client rights within physical therapy services. Available at: http://www.apta.org/Policies/Practice/. Accessed on February 12, 2018.
  3. American Physical Therapy Association. APTA Guide for professional conduct. American Physical Therapy Association. Updated September 9, 2013. Available at: http://www.apta.org/Ethics/Core/. Accessed on February 12, 2018.
  4. American Physical Therapy Association. APTA Guide for conduct of the physical therapist assistant. Last updated September 9, 2013. Available at: http://www.apta.org/Ethics/Core/. Accessed on February 12, 2018.
  5. American Physical Therapy Association. Code of Ethics for the Physical Therapist. Available at: http://www.apta.org/Ethics/Core/. Accessed on February 12, 2018.
  6. American Physical Therapy Association. Direction and supervision of the physical therapist assistant. American Physical Therapy Association. Last updated August 7, 2012. Available at: http://www.apta.org/Policies/Practice/. Accessed on February 12, 2018.
  7. American Physical Therapy Association. Guide to physical therapist practice. 2nd Edition revised. American Physical Therapy Association. January 2003. Originally published as: Guide to Physical Therapist Practice. Phys Ther. 2001; 81:9-744.
  8. American Physical Therapy Association. Guidelines for physical therapy documentation of patient/client management. Last updated May 19, 2014. Available at: http://www.apta.org/search.aspx?q=guidelines for physical therapy documentation. Accessed on February 12, 2018.
  9. American Physical Therapy Association. Physical therapy for older adult. Last updated August 7, 2012. Available at: http://www.apta.org/Policies/Practice/. Accessed on February 12, 2018.
  10. American Physical Therapy Association. Provision of physical therapy interventions and related tasks. Last updated August 7, 2012. Available at: http://www.apta.org/Policies/Practice/. Accessed on February 12, 2018.
  11. American Physical Therapy Association. Standards of practice for physical therapy. Last updated October 1, 2013. Available at: http://www.apta.org/Policies/Practice/. Accessed on February 12, 2018.
  12. Centers for Disease Control and Prevention. Developmental monitoring and screening for health professionals. January 3, 2017. Available at: http://www.cdc.gov/ncbddd/childdevelopment/screening-hcp.html. Accessed on February 12, 2018.
  13. Centers for Disease Control and Prevention. Developmental screening tools. Developmental screening and assessment instruments with an emphasis on social and emotional development for young children ages birth through five. May 2008. Available at: http://www.nectac.org/~pdfs/pubs/screening.pdf. Accessed on February 12, 2018.
  14. Centers for Medicare & Medicaid Services (CMS). Pub. 100-02, Chapter 15, Sections 220. Coverage of Outpatient Rehabilitation Therapy Services (Physical Therapy, Occupational Therapy, and Speech-Language Pathology Services) Under Medical Insurance and Section 230. Practice of Physical Therapy, Occupational Therapy, and Speech-Language Pathology. September 9, 2014. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed on February 12, 2018.
  15. Centers for Medicare & Medicaid Services. Manuals. Available at: http://www.cms.hhs.gov/Manuals/PBM/list.asp. Accessed on February 12, 2018.
    • Home Health Agency Manual. Pub. 11. Chapter 2, Section 205.2 Coverage of Services Which Establish Home Health Eligibility. Skilled Therapy Services. Last updated December 05, 2015.
    • Hospital Manual. Pub. 10. Chapter2, Section 210.8. Physical Therapy Furnished by the Hospital or by Others Under Arrangements With the Hospital and Under its Supervision. Last updated September 8, 2005.
    • Outpatient Physical Therapy Comprehensive Outpatient Rehabilitation Facility and Community Mental Health Center Manual. Pub. 9. Chapter 2, Coverage of Services. Last updated September 8, 2005.
  16. Centers for Medicare & Medicaid Services. National Coverage Determination for Institutional and Home Care Patient Education Programs. NCD#170.1. Effective date not posted. Available at: http://www.cms.hhs.gov/mcd/index_list.asp?list_type=ncd. Accessed on February 12, 2018.
  17. Hegmann KT, ed. Low back disorders. In: Glass LS, editor(s). Occupational medicine practice guidelines: Evaluation and management of common health problems and functional recovery in workers. 2nd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine (ACOEM); 2007.
  18. Miller EL, Murray L, Richards L, et al. Comprehensive overview of nursing and interdisciplinary rehabilitation care of the stroke patient: a scientific statement from the American Heart Association. Stroke. 2010; 41(10):2402-2448.
  19. NIH Consensus Statement. Rehabilitation of persons with traumatic brain injury. 1998 Oct 26-28; 16(1):1-41. Available at: http://www.nichd.nih.gov/publications/pubs/TBI_1999/Pages/NIH_Consensus_Statement.aspx. Accessed on February 12, 2018.
  20. Sneed RC, May WL, Stencel C. Physicians’ reliance on specialists, therapists, and vendors when prescribing therapies and durable medical equipment for children with special health care needs. Pediatrics. 2001; 107(6):1283-1290.
Index

Physical Therapy
Physiotherapy
PT (Physical Therapy)

History

Status

Date

Action

Revised

03/22/2018

Medical Policy & Technology Assessment Committee (MPTAC) review. Reformatted NMN criteria. Added NMN statement to address other uses for physical therapy services. Added Discussion/General Information section. Updated References sections. Updated coding section to add CPT codes 97169, 97170, 97171, and 97172.

Reviewed

01/25/2018

MPTAC review. Updated References section.

 

12/27/2017

The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Coding section with 01/01/2018 CPT and HCPCS changes; added 97127, 97763, G0515 and modifiers 96, 97; revised descriptors for 97760, 97761; removed 97532, 97762 and modifier SZ deleted 12/31/2017.

Revised

02/02/2017

MPTAC review. Clarified MN and NMN habilitative therapy criteria. Reformatted clinical indication section. Updated Definitions and Reference sections.

 

01/01/2017

Updated Coding section with 01/01/2017 CPT changes; removed codes 97001, 97002 deleted 12/31/2016.

Reviewed

05/05/2016

MPTAC review. Updated Reference section. Removed ICD-9 codes from Coding section.

Reviewed

05/07/2015

MPTAC review. Updated Coding, Description and References.

Revised

05/15/2014

MPTAC review. Reformatted medically necessary criteria for rehabilitative therapy. Revised medically necessary criteria to address habilitative therapy. Clarified not medically necessary criteria addressing rehabilitative therapy, maintenance therapy, and duplicate therapy. Revised not medically therapy criteria to address habilitative therapy. Updated Description, Definitions, References and Websites. Updated coding section with HCPCS modifier ‘-SZ’ effective 07/01/2014.

Reviewed

02/13/2014

MPTAC review. Updated Websites and Coding.

Reviewed

02/14/2013

MPTAC review. Updated Websites.

Reviewed

08/09/2012

MPTAC review. Updated Websites and references.

 

01/01/2012

Updated Coding section to add code S8990; removed revenue codes 0420-0429.

Reviewed

08/18/2011

MPTAC review. Updated websites and references.

 

01/01/2011

Updated Coding section with 01/01/2011 CPT and HCPCS changes.

Revised

08/19/2010

MPTAC review. Clarified language in Providers of Physical Therapy (PT) Services section stating that physical therapists are required to have licensure and have passed the National Physical Therapy Exam (NPTE) and that other qualified providers of PT are required to act within the scope of their licenses. Websites and references updated.

 

01/01/2010

Updated Coding section with 01/01/2010 HCPCS changes.

Reviewed

08/27/2009

MPTAC review. Remove Place of Service/Duration section. References and coding updated.

Reviewed

08/28/2008

MPTAC review. References updated.

Reviewed

08/23/2007

MPTAC review. References and Coding section updated.

Revised

09/14/2006

MPTAC review. Minor revision to Not Medically Necessary statement. References updated.

Revised

12/01/2005

MPTAC review. Revision based on Pre-merger Anthem and Pre-merger WellPoint Harmonization.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem Midwest

08/06/2004

RA-008 (Midwest Medical Review & UM criteria)

Physical Therapy / Occupational Therapy For NASCO, Prestandardized Medicare Supplement Plans, Group Blue Retiree Products, And FEP

WellPoint Health Networks, Inc.

04/28/2005

10.01.08

Physical Therapy