Policy

Outpatient Rehabilitation Therapy Services billed to Medicare Part B (L28531)

Contractor Information

Contractor Name
Wisconsin Physicians Service Insurance Corporation

Contractor Number
00951, 00952, 00953, 00954, 05102, 05202, 05302, 05402

Contractor Type
Carrier - MAC B

LCD Information

Document Information

LCD ID Number
L28531

LCD Title
Outpatient Rehabilitation Therapy Services billed to Medicare Part B

Contractor's Determination Number
PHYSMED-009

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

Oversight Region

Original Determination Effective Date
For services performed on or after 01/15/2010

Original Determination Ending Date

Revision Effective Date
For services performed on or after 11/01/2011

Revision Ending Date

CMS National Coverage Policy

Title XVIII of the Social Security Act, § 1861 (s)(2)
Title XVIII of the Social Security Act, § 1862 (a)(14)
Title XVIII of the Social Security Act, § 1862(a)(7)
Title XVIII of the Social Security Act, Section 1833(e)
Title XVIII of the Social Security Act, Section 1862(a)(1)(A)
CMS Publication 100-01 Medicare General Information, Eligibility and Entitlement Manual
CMS Publication 100-02 Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230
CMS Publication 100-03 Medicare National Coverage Determinations
CMS Publication 100-04 Medicare Claims Processing Manual
CMS Publication 100-08 Medicare Program Integrity Manual
CMS Publication 100-19, Medicare Demonstrations Manual, Transmittal No. 10, Change Request #3346, November 19, 2004.
CMS Transmittal 515, April 1, 2005 Pub 100-04, §20 "always therapy codes."
CMS Transmittal 60 CR#5271 "Active Participant"
CMS Transmittal 88, CR#5921 "Therapy personnel qualifications and timing of recertification of plans of care
CMS Transmittal 34, CR 3648
CMS Transmittal AB-01-135, CR 1793
CMS Transmittal AB-02-078, CR 2083
Code of Federal Regulations, Title 42, 410.60, 410.61, 410.74, 410.75, 410.76, 419.22, 424.24 (c), 486, 1835 (a) (2) (D), 1861 (r)

Indications and Limitations of Coverage and/or Medical Necessity

I. Introduction
This Local Coverage Determination (LCD) is for physical medicine and rehabilitation procedures billed to Medicare Part B. Providers who submit claims to Medicare Part A should follow the Medicare guidelines in the regulations listed in the section entitled "CMS National Coverage Policy."

The Outpatient Rehabilitation Therapy Services listed in this LCD must be provided by a qualified professional as defined in Chapter 15 of the Medicare Benefit Policy Manual. A qualified professional means a physical therapist, occupational therapist, physician, nurse practitioner, clinical nurse specialist, or physician's assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies. Qualified professionals may also include physical therapy assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law. Assistants may not supervise others.

The patient must be under the care of and referred for therapy services by a 'qualified professional':
An order (sometimes called a referral) for therapy service, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. However, the certification requirements are met when the physician certifies the plan of care. If the signed order includes a plan of care (see essential requirements of plan in §220.1.2), no further certification of the plan is required. Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan.

1. Physicians (a doctor of medicine, osteopathy, podiatry, optometry [Visual Rehab. Only]), performing skilled therapy services, in an outpatient setting, as their own professional services or as supervisor of services performed by their qualified personnel (staff) furnished incident-to their professional services;
2. Non-physician practitioners (NPP) (physicians assistant, nurse practitioner, clinical nurse specialist, (acting within the scope of their state license), in an outpatient setting, performing skilled therapy services as their own professional services or as supervisor of services performed by their qualified personnel (staff) furnished incident-to their professional services;
3. Physical therapists (PT) (For Medicare Part B - in independent practice), performing skilled therapy services as their own professional services or as supervisor of services performed by their qualified personnel (staff) under their direct supervision; or
4. Occupational therapists (OT) (For Medicare Part B - in independent practice), performing skilled therapy services as their own professional services or as supervisor of services performed by their qualified personnel (staff) under their direct supervision.
5. Skills of a therapist are defined by the scope of practice for the therapist in the state the service is rendered.

Appropriate portions of the therapy service may be performed by a physical therapy assistant (PTA), but ONLY under the supervision of a physical therapist. For Medicare, the PTA may NOT perform PT directly "incident-to" a physician, because the PTA does not have all the qualifications of a therapist.

Appropriate portions of the therapy service may be performed by an occupational therapy assistant (OTA), but ONLY under the supervision of an occupational therapist. For Medicare, the OTA may NOT perform OT directly "incident-to" a physician, because the OTA does not have all the qualifications of a therapist.

Services may not be billed under the incident to provision unless they are performed in place of service office or in a clinic that is owned by the professional group billing for the services. This means that all therapy services must be personally performed by the person who is billing for the service when the service is performed in any other place of service.

Note that because a service is considered an outpatient rehabilitation service does not automatically imply payment for that service. The additional criteria listed below, including coverage, plan of care and physician/NPP certification and medical necessity of the service must also be met. Qualified practitioners treating beneficiaries being cared for under the Home Health Benefit (HHA) would not bill their services under a Part A or Part B home health plan of care, but rendered under a therapy plan of care.

Medicare services provided to beneficiaries under a home health plan of care are subject to consolidated billing provisions and would not be submitted to Medicare Part B.

Physical medicine and rehabilitation services are covered under the Medicare Benefit provided such services are of a level of complexity and sophistication, or the patient's condition is such that the services can be safely and effectively performed only by a licensed PT/OT or Licensed PTA/OTA.

There must be an expectation that the beneficiary's condition will improve significantly in a reasonable and generally predictable period of time based on the physician's/NPP's assessment of the patient's rehabilitation potential, after any needed consultation with the qualified therapist or the services must be necessary to establish a safe and effective maintenance program in connection with a specific disease state.

The goal for a patient is to return to the highest level of function realistically attainable and within the context of the disability. The skills of the therapist may not necessarily be required to attain this goal but may be required initially to ensure safety, proper modality performance, etc. then transferring their care to a caregiver and home exercise program (HEP). Services normally considered to be a routine part of nursing care are not covered as physical therapy or occupational therapy (i.e., turning patients to prevent pressure injuries or walking a patient in the hallway postoperatively).

A. EVALUATION/RE-EVALUATION AND PLAN OF CARE.

Covered physical medicine and rehabilitation services must relate directly and specifically to a certified plan of care and must be reasonable and necessary to the treatment of the individual's illness or injury

The plan of care should address specific therapeutic goals for which modalities and procedures are outlined in terms of type, frequency and duration. The plan must be certified/approved by the physician/NPP or optometrist (Visual Rehab. only). The plan must be certified within 30 days following the first day of treatment (including evaluation). The plan must be reviewed, dated and signed by a physician/NPP at least every 90 days. If the order is verbal, it must be followed within 14 days by a signature

B EPISODE OF CARE
An outpatient therapy episode is defined as the period of time, in calendar days, from the first day the patient is under the care of the clinician (e.g., for evaluation or treatment) for the current condition(s) being treated by one therapy discipline (PT, or OT, or SLP) until the last date of service for that discipline in that setting. During the episode, the beneficiary may be treated for more than one condition; including conditions with an onset after the episode has begun.

C. DIRECT SUPERVISION
"PT/OT/SPL services performed by a qualified therapist employed by a physician/NPP or physician/NPP group without a Medicare NPI should be reported to Medicare under the physicians/NPPs Medicare NPI, with an appropriate HCPCS/CPT code and the appropriate therapy modifier (GN, GO, GP). The physician/NPP must be physically present in the same office suite and immediately available to provide assistance and direction throughout the time the employee is performing services."

Services provided by aides, even if under the supervision of a clinician, are not therapy services in the outpatient setting and are not covered by Medicare. Although an aide may help the clinician by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services. (https://www.cms.gov/manuals/Downloads/bp102c15.pdf page 187)

*Note: Title 18, Section 1861 clearly states that the practice of medicine and all allied services are dependent on the rules and regulations within the state in which the individual practices. It is the responsibility of the physician/nonphysician practitioner to be in compliance with state regulations governing the licensing requirements of employees to provide specific services including limitations on the number of employees that can be adequately supervised.

D. VISITS OR TREATMENT SESSIONS
Visits or treatment sessions begin at the time the patient enters the treatment area (of a building, office or clinic) and continues until all services (e.g., activities, procedures, services) have been completed for that session and the patient leaves that area to participate in a non-therapy activity. It is likely that not all minutes in the visits/treatment sessions are billable (e.g., rest periods). There may be two treatment sessions in a day, for example, in the morning and afternoon. When there are two visits/treatment sessions in a day, plans of care indicate treatment amount of twice a day. (Pub 100-2, Chap. 15, Section 220)

E. INCIDENT TO:
Therapy services appropriately billed incident to a physician's/NPP's service shall be subject to the same requirements as therapy services that would be furnished by a physical therapist or occupational therapist in any other outpatient setting with one exception. When therapy services are performed incident to a physician's/NPP's service, the personnel who perform the service do not need to have a license to practice therapy, unless it is required by state law. The qualified personnel must meet all the other requirements except licensure

Therapy services may be provided incident to the services of a physician/NPP under §§1861(s)(2) and 1862(a)(20) of the Act. This term means services that are:
1. Furnished as an integral, although incidental, part of a physician/NPP's personal professional services;
2. Performed under the physician/NPP's direct supervision;
3. Performed by qualified clinicians or other qualified auxiliary personnel who are employees of the physician/NPP (as defined above); and
4. Furnished during a course of treatment where the physician/NPP performs an initial direct, personal, professional service and performs subsequent services at a frequency that reflects his/her continuing active participation in and management of the course of treatment.
5. The services of a PTA or OTA shall not be billed as services incident to a physician/NPP's service, because they do not meet the qualifications of a clinician.
There must be a valid employment arrangement between the clinician, physician/NPP physician directed clinic, and the employee. If all the above conditions are not met, the service is not truly 'incident to' and cannot be billed under the physician's NPI number.

The qualified personnel must meet all the other requirements except licensure. Qualifications for clinicians are found in 42CFR484.4 and in section 230.1, 230.2, and 230.3 of the Medicare Benefit Policy Manual, Pub 100-02. In effect, these rules require that the person who furnishes the service to the patient must, at least, be a graduate of a program of training for one of the therapy services as described above. Regardless of any state licensing that allows other health professionals to provide therapy services, Medicare is authorized to pay only for services provided by those trained specifically in physical therapy or occupational therapy. That means that the services of athletic trainers, massage therapists, recreation therapists, kinesiotherapist, low vision specialist or any other profession that is not eligible for a Medicare Part B Provider number may not be billed as therapy services.

II. GENERAL PHYSICAL MEDICINE AND REHABILITATION GUIDELINES

The following services are typically considered rehabilitative. Therapy services should be provided in a manner that meets the patients need. The plan of care should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources. Because medical review decisions are made based on documentation in the medical record, this LCD provides recommendations intended to assist qualified professionals/assistive personnel in documenting to support both the medical necessity and the skilled nature of the therapy services provided. In addition, any numerical guidelines related to individual codes in this section of the LCD are based on contractor medical review experience. The guidelines presented under the sections are not mandated, and it is not necessary to document these recommended points for each treatment session, unless otherwise specified in the LCD. Please refer to CMS publication 100-02, Medicare Benefit Policy Manual, Chapter 15, section 220.3 for the Medicare minimal documentation requirements for therapy services.

A. EVALUATION SERVICES
Evaluations are required prior to beginning therapy for determining the medical necessity of initiating rehabilitative or maintenance services.

CPT CODE 97001: PHYSICAL THERAPY EVALUATION:
CPT CODE 97003: OCCUPATIONAL THERAPY EVALUATION:
1. Evaluation are performed and billed by licensed physical therapists/occupational therapist in independent practice. Physical therapy assistants/occupational therapy assists under the direct supervision of the physical therapist/occupational therapist may assist in this process, but may not perform the evaluation. Other tests and measurement services may not be billed on the same date of services as the initial PT/OT evaluation.
2. An initial evaluation is required prior to beginning therapy for determining the medical necessity of initiating PM & R services or a maintenance program
3. Factors that influence the complexity of the examination and evaluation process include the clinical findings of the current problem, the severity and extent of the loss of function, the presence of pre-existing systemic conditions and the stability of that condition, the living environment, social support and the patient's overall physical function and health status to determine the patient's rehabilitation potential. Reimbursement for the evaluation is based on the visit itself and not the time spent performing the evaluation.
4. Initial PT/OT evaluations may be considered reasonable and necessary when the evaluation determines that skilled rehabilitation services are not needed by the patient or when the patient's condition indicates there is no rehabilitation potential, and only the development of a maintenance program is needed
5. PM & R modalities and therapeutic procedures may be performed on the same date of service as the initial evaluation. Documentation of the intervention must be included in the patient's medical records.

CPT CODE 97002: PHYSICAL THERAPY RE-EVALUATION:
CPT CODE 97004: OCCUPATIONAL THERAPY RE-EVALUATION:

1. Re-evaluation are performed and billed by licensed therapists in independent practice. Physical therapy assistants/occupational therapy assistants under the direct supervision of the physical therapist/ occupational therapist may assist in this process, but may not perform the re-evaluation. Other tests and measurement services may not be billed on the same date of services as the PT re-evaluation. (Reference CCI)
2. CPT codes 97002 and CPT code 97004 are intended for formal periodic re-evaluations, and contain the same components as the initial evaluation, but are focused on assessing significant changes from the initial evaluation or progress toward treatment goals. It is not medically necessary or the standard of practice to routinely perform and report a re-evaluation service on each PM & R treatment date of service subsequent to the initial evaluation or for the Interval Progress Report.
3. Medicare policy requires a re-certification of the plan of care by the attending physician/NPP at least every 90 days for both CPT codes 97002 and 97004 services. In order to identify the need for continued treatment, and comply with this regulation, it would be considered reasonable and necessary for the clinician to perform a re-evaluation for the re-certification process.

B. RE-EVALUATION AND PLAN OF CARE

Indications for a re-evaluation include new clinical findings, a significant change in the patient's condition, or failure to respond to the therapeutic interventions outlined in the plan of care. A re-evaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or for the use of the qualified professional or the treatment setting at which treatment will be continued.

A re-evaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment or terminating services. Reevaluation requires the same professional skills as evaluation. The minutes for reevaluation are documented in the same manner as the minutes for evaluation.

A re-evaluation may be considered reasonable and necessary when there is a change in the patient's condition and the clinician determines a change in the plan of care is warranted. This may occur at anytime during the treatment program and should be substantiated in the documentation. Re-evaluation may be considered reasonable and necessary when it is determined the skilled rehabilitation services are no longer needed for the patient's condition and the development of a maintenance program is indicated. This may be as a result of the patient reaching the set goals or that the patient's conditions limits further improvement. Re-evaluation is considered reasonable and necessary to readjust an established maintenance program and for periodic assessment of the patient on in a maintenance program.

Physician /NPP certification of the significantly modified plan of care shall be obtained within 30 days of the initial therapy treatment under the revised plan of care.

Plan of Care. See section 220.1.2 for requirements of the plan. The evaluation and plan may be reported in two separate documents or a single combined document.

C. MAINTENANCE THERAPY SERVICES

Evaluation and management services or PT/OT evaluations/re-evaluations would be considered medically necessary in the development of maintenance program when:
1. Skilled therapy services are not needed by the patient,
2. The patient' condition indicates there is no rehabilitation potential, or
3. The goals of the active therapy have been reached, but in all of the above a maintenance regimen is required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease;

The evaluation services would include:
1. The design of a maintenance regimen required to delay or minimize muscular and functional deterioration in patients suffering from a chronic disease;
2 Instructions to the patient or family members in carrying out the maintenance program; and
3. The infrequent reevaluations required to assess the patient's condition and adjust the program.

NOTE:
Because dementia is a diagnostic term with broad clinical implications, it does not support the medical necessity of a Medicare covered benefit when used alone. When a beneficiary with dementia experiences an illness or injury unrelated to the dementia, the qualified practitioner should submit a claim with the primary diagnosis that most accurately reflects the need for the provided service. For example, following a hip replacement in a patient with Alzheimer's Disease, a qualified practitioner could submit a clean claim using ICD-9 Code V43.64 (Hip joint replacement by artificial or mechanical device or prosthesis) as the primary diagnosis, not ICD-9 code 331.0 (Alzheimer's Disease)." (CMS Transmittal AB-01-135) Clinicians should include a functional diagnosis, such as difficulty walking or weakness, as the primary diagnosis and may place a diagnosis such as V43.64 as the secondary diagnosis. If the patient's dementia is so severe that they would not benefit from the therapy, it would be inappropriate to bill for these services.

D. THERAPY FOR PATIENTS WITH SYMPTOMS FROM CHRONIC DISEASE:

1. Use the ICD-9-CM code for the sign/symptom/complication diagnosis. The underlying condition may also be coded, but is not required.
2. Periodic evaluations of the patient's condition and response to treatment may be covered when medically necessary if the judgment and skills clinician are required. Examples include:

Design of a home therapy regimen required to delay or minimize muscular and functional deterioration in patients suffering from chronic disease;
Instructing the patient or/and family members in carrying out the therapy program; and,

Infrequent re-evaluations required to assess the patient's condition and adjust the program. These services should be billed with the appropriate CPT code (e.g., CPT code 99212-99215 for physicians or NPPs; CPT code 97001-97004 for PT and OT only). It is expected that these services will be infrequently required.
3. It is not medically reasonable and necessary for a qualified practitioner to perform or supervise therapy programs that do not require the professional skills of a qualified practitioner. These situations include:

Services related to activities for the general good and welfare of patients (i.e., general exercises to promote overall fitness and flexibility in an otherwise healthy patient);

Repetitive exercises to maintain gait or maintain strength and endurance, and assisted walking such as that provided in support for feeble or unstable patients;

Range of motion and passive exercises that are not related to restoration of a specific loss of function, but are useful in maintaining range of motion in paralyzed extremities; and Continued therapies after the patient has achieved therapeutic goals or for patients who show no further meaningful progress.

Maintenance therapy is not covered.

E. GENERAL MODALITY GUIDELINES:
CPT codes 97010-97039

The uses of modalities as stand-alone treatments are rarely therapeutic, and usually not required or indicated as the sole treatment approach to a patient's condition. The use of exercise and activities has proven to be an essential part of a therapeutic program. Therefore, a plan of care should not consist solely of modalities, but should also include therapeutic procedures. Example of exception is when a patient is unable to endure therapeutic procedures due to the acuteness of the condition. If a patient is unable to endure therapeutic procedures due to the acuteness of the condition, the number of visits for modalities should not exceed 2-4 visits. Documentation and patient condition must justify treatment that is inconsistent with this provision

1. Modality CPT Codes 97012-97028 require supervision (but not one-on-one) by the qualified practitioner; and CPT codes 97032-97039 require direct (one-on-one) contact with the patient by the qualified practitioner. These services may be provided "incident to" a physician/NPP's services and, if so, must be directly supervised by the physician/NPP in his/her office.
2. Traction and paraffin bath equipment for the patient's home use is covered by the Durable Medical Equipment Regional Contractor (DMERC) and claims are submitted to them, services are governed under their jurisdiction.
3. Documentation of the medical necessity of multiple heating modalities (CPT codes 97018, 97024, 97026, 97034, 97035) on the same day must be available for review.
4. Modalities may be considered components of other modalities and procedures and will not be separately reimbursed. Please refer to the National Correct Coding Initiative which can be found on the CMS Website (https://www.cms.gov/NationalCorrectCodInitEd/). Documentation must be available supporting the use of multiple modalities as contributing to the patient's progress and restoration of function.
5. Documentation for modalities must include the area/areas treated and the patient's response to treatment, the response of patient and/or caregiver to education, functional progress at reassessment and discharge. If no progress, the reason for lack of progress and /or alternative treatment strategy.

F. SPECIFIC MODALITY GUIDELINES:

The following clinical guidelines pertain to the specific modalities listed below

CPT code 97010 Application of a modality to one or more areas; hot or cold packs

CPT code 97010 is bundled into the payment for other services and is not separately reimbursable.
1. Hot/cold packs are a covered service; however not separately reimbursable. When CPT code 97010 is billed there will be no separate payment (i.e. bundled).
2. NOTE: Hot/cold packs (including Aquamed) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a licensed clinician.
3. Regardless of whether CPT code 97010 is billed alone or in conjunction with another therapy code, these modalities are considered non-skilled services and are not separately reimbursable.
4. Only one unit or service of CPT code 97010 is covered per date of service.

CPT code 97012 Application of a modality to one or more areas; traction, mechanical
1. Traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas.
2. Supervised treatment would generally not be expected to exceed up to 4 sessions per week for longer than one month. Documentation must support medical necessity of this service which is typically used in conjunction with therapeutic procedures, not as an isolated treatment.
3. Claims for covered traction equipment for home use are submitted to the DMERC. Documentation supporting the medical necessity for the continued treatment by a supplier should be made available to the Carrier on request.
4. Equipment and tables utilizing roller systems are not considered as true mechanical traction. Services using this type of equipment are non-covered.
5. Vertebral axial decompression (VAX-D) is performed by some clinicians for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. However, there is insufficient scientific data to support the benefits of this technique. Therefore, VAX-D is considered non-covered.
6. Only one unit or service of CPT code 97012 is covered per date of service.

CPT code 97016 Application of a modality to one or more areas; vasopneumatic devices
1. Specific indications for the use of vasopneumatic devices include reduction of edema after acute injury and lymphedema of an extremity
NOTE:
Claims for Pneumatic Compression Devices used in the home setting to treatment of chronic lymphedema and chronic venous insufficiency it is covered by the DMERC and governed under their jurisdiction.

2. Documentation must support the educational visits and treatment of lymphedema by the physician/NPP/clinician.
3. Documentation must include objective edema measurements with comparison to the uninvolved side, description of edema, i.e., pitting, non-pitting, effect of edema on function and the type of device used.

CPT code 97018: Application of a modality to one or more areas; paraffin bath
Also known as hot wax treatment, is primarily used for pain relief in chronic joint problems of the wrists, hands or feet.
NOTE: Claims for Paraffin Bath equipment for home treatment of this condition are submitted the DMERC and services are governed by their jurisdiction.
1. Examples of indications for the use of paraffin bath include:
Contracture as result of rheumatoid arthritis;
Contracture as result of scleroderma;
Acute synovitis;
Post-traumatic conditions;
Hypertrophic scarring;
Degenerative joint disease;
Osteoarthritis;
Post-surgical conditions or tendon repairs;
Status post sprains or strains.
2. Only one service or unit of CPT code 97018 per area is covered per date of service.
3. No greater than 2 visits will generally be covered to educate patient and/or caregiver in home use and to evaluate effectiveness of the treatment.

CPT code 97022 Application of a modality to one or more areas; whirlpool
1. The objective of these treatments is to cause vasodilatation and relieve pain from muscle spasm. It is not medically necessary to have more than one form of hydrotherapy (CPT codes 97022, 97036, 97113) during the same visit.
2. Continued treatment by a qualified practitioner requires documentation supportive of medical necessity.

Fluidotherapy is a dry whirlpool modality using finely ground cellulose particles (crushed corncobs) in a cabinet. Heat and air are forced through the particles, causing them to flow like a liquid around the area being treated, providing a superficial heat. Fluidotherapy is most often applied to the distal end of extremities. This is generally used to increase blood flow, encourage muscle relaxation and relieve pain for conditions of the hands and feet. This may be considered medically necessary when used in conjunction with therapeutic procedures, but is considered a non-skilled therapy services and rarely medically necessary when reported alone. CPT code 97022 should be used for this modality

CPT code 97024 Application of a modality to one or more areas; diathermy
1. The use of diathermy is considered reasonable and necessary for the delivery of heat to deep tissues such as skeletal muscle and joints for the reduction of pain, joint stiffness, and muscle spasms. Examples of indications for the use of diathermy include:
Osteoarthritis, rheumatoid arthritis, or traumatic arthritis;
Strain or sprain(s)
Acute or chronic bursitis;
Traumatic injury to muscle, ligament, or tendon resulting in functional loss;
Joint dislocation or subluxation;
Treatment for a post surgical functional loss;
Adhesive capsulitis;
Joint contracture.
2. Diathermy is not considered reasonable and necessary for the treatment of asthma, bronchitis, or any other pulmonary condition.
3. Only one service or unit of CPT code 97024 is covered per date of service.
4. Clinicians should continually reassess the patient to determine the effectiveness of the interventions provided. If progress is not seen, the clinician should consider a change in the plan of care or ensure that documentation justifies continuation of the established plan of care.
5. Documentation should include the fact that the treatment performed is short wave diathermy.
6. Because there is no substantial evidence from published, controlled clinical studies demonstrating the efficacy of microwave diathermy modality, this service will be denied as not proven effective.

CPT code 97026 Application of a modality to one or more areas; infrared
Limited coverage per CMS Publication 100-03 Medicare National Coverage Determinations (NCD) Manual, section 270.6 and Publication 100-04, Medicare Claims Processing Manual, Chapter 5, section 20.4.

*The use of infrared and/or near-infrared light and/or heat, including monochromatic infrared energy, is non-covered for the treatment, including symptoms such as pain arising from these conditions, of diabetic and/or non-diabetic peripheral sensory neuropathy, wounds and/or ulcers of the skin and/or subcutaneous tissues in Medicare beneficiaries. Claims with CPT 97026 (infrared therapy incident to or as a PT/OT benefit) that contain any of the following ICD-9 codes will be denied - all other claims will be subjected to the same medical necessity criteria contained in this LCD.:
250.60-250.63, 354.4, 354.5, 354.9, 355.1-355.4, 355.6-355.9, 356.0, 356.2-356.4, 356.8-356.9, 357.0-357.7, 674.10, 674.12, 674.14, 674.20, 674.22, 674.24, 707.00-707.07, 707.09-707.15, 707.19, 870.0-879.9, 880.00-887.7, 890.0-897.7, 998.31-998.32.

Photobiostimulation: (low level laser therapy, light force therapy, low power laser therapy, cold laser therapy, etc.) This is therapy is generally used for the treatment of pain; many of the devices are approved by the FDA for home use. This may be considered medically necessary when used in conjunction with therapeutic procedures, but is considered a non-skilled therapy service and rarely medically necessary when reported alone

CPT code 97028 Application of a modality to one or more areas; ultraviolet
1. Treatment of this type is generally used for patients requiring the application of a drying heat. For example, this treatment would be considered reasonable and necessary for the treatment of severe psoriasis where there is limited range of motion.
2. Only one service or unit of CPT code 97028 is covered per date of service.
This supervised modality uses a form of light energy to primarily treat skin conditions.
Each treatment must be documented in accordance with the established plan of care.
The treatment is not indicated in non-dermatological conditions

Electrical Stimulation
CPT code 97032, HCPCS G0281, HCPCS G0283, HCPCS G0329 - Electrical Stimulation

CPT code 97032 Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
CPT code 97032 is a constant attendance electrical stimulation modality that requires direct (one-on-one) manual patient contact by the qualified professional/auxiliary personnel. Because the use of a constant, direct contact electrical stimulation modality is less frequent, documentation should clearly describe the type of electrical stimulation provided to justify billing CPT 97032 versus HCPCS code G0283.

Types of electrical stimulation that may require constant attendance and should be billed as CPT 97032 when continuous presence by the qualified professional/auxiliary personnel is required include the following examples.
1. Direct motor point stimulation delivered via a probe
2. Instructing a patient in the use of a home TENS unit; a beneficiary can usually be taught to use a TENS unit for pain control in 1-2 visits. Consequently, it is inappropriate for a patient to continue treatment for pain with a TENS unit in the clinic setting.
3. Functional Electrical Stimulation (FES) or Neuromuscular Electrical Stimulation (NMES) while performing a therapeutic exercise or functional activity may be billed as CPT 97032. Do not bill for CPT codes 97110, 97112, 97116 or 97530 for the same time period.
4. Non-implantable pelvic floor electrical stimulators provide neuromuscular electrical stimulation through the pelvic floor with the intent of strengthening and exercising pelvic floor musculature. Stimulation delivered by vaginal or anal probes connected to an external pulse generator may be billed as CPT code 97032. (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, section 230.8.)
5. Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.
6. A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength.
7. The patient's medical record must indicate that the patient receiving a non-implantable pelvic floor electrical stimulator was cognitively intact, motivated, and had failed a documented trial of pelvic muscle exercise (PME) training.

Utilization of electrical stimulation may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement.

Note: Coverage for this indication is limited to those patients where the nerve supply to the muscle is intact, including brain, spinal cord, and peripheral nerves and other non-neurological reasons for disuse are causing the atrophy (e.g., post-casting or splinting of a limb, and contracture due to soft tissue scarring).

Documentation must clearly support the medical necessity of electrical stimulation more than 12 visits as adjunctive therapy or for muscle retraining.

Non-covered Indications:
1. Electrical Stimulation (CPT code 97032) used in the treatment of facial nerve paralysis, commonly known as Bell's palsy (CMS Manual 100-03, Medicare National Coverage Determinations (NCD) Manual, section 160.15).
2. Electrical Stimulation (CPT code 97032) used to treat motor function disorders such as multiple sclerosis (CMS Manual 100-03, Medicare National Coverage Determinations (NCD) Manual, section 160.2).
3. Electrical Stimulation (CPT code 97032) for the treatment of strokes when it is determined there is no potential for restoration of function.
4. Electrical Stimulation used when it is the only intervention utilized purely for strengthening of a muscle with at least Fair graded strength. Most muscle strengthening is more efficiently accomplished through a treatment program that includes active procedures such as therapeutic exercises and therapeutic activities.

Supportive Documentation Recommendations for CPT code 97032
1. Type of electrical stimulation used (do not limit the description to "manual" or "attended")
Area(s) being treated.
2. If used for muscle weakness, objective rating of strength and functional deficits
3. If used for pain include pain rating, location of pain, effect of pain on function

HCPSC codes G0281, G0329

HCPCS Code 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

SPECIFIC MODALITY CLINICAL GUIDELINES:

CPT code 64550 - Application of Surface (Transcutaneous) Neurostimulator
1. This code is not covered on the same visit date with HCPCS G0283 or CPT code 97032.
2. Once the patient has been instructed on the use/placement of the home TENS unit, G0283 is no longer be covered.

HCPCS Code G0283 Electrical stimulation, (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
1. Non-implantable pelvic floor electrical stimulators are used in the treatment of stress and/or urge urinary incontinence. One or two office treatments may be medically necessary to determine the effectiveness of treatment and for patient education in use of the home equipment. When this device is used in the home claims are submitted to the DMERC and services are governed under their jurisdiction. (See CMS National Coverage Determination Manual CMS Pub.100-03 Part 4 §230.8)
2. Biofeedback Therapy and Biofeedback Training in Urinary Incontinence are indicated for specified conditions. (See PHYS-066)
3. This code should be used if electrical stimulation units are placed on the patient by the qualified practitioner and do not require the continued presence and direct one-on-one contact by the qualified practitioner once set-up is completed. If electrical stimulation is applied manually and direct one-on-one contact is provided by the clinician, CPT code 97032 should be used.
4. Interferential current/medium current (IFC) units use a frequency that allows the current to go deeper into the tissue. IFC is used to control swelling and pain. Documentation must support the need for continued treatment with this modality for greater than 12 visits.
5. Utilization of these modalities may be necessary during the initial phase of treatment, but there must be an improvement in function. These modalities should be utilized with appropriate therapeutic procedures to effect continued improvement. A limited number of visits without a therapeutic procedure may be medically necessary for treatment of muscle spasm and swelling, but this should not exceed 2-4 visits since this service is covered by HCPCS G0283.

Neuromuscular Electrical Stimulator (NMES) for Disuse Atrophy
Treatment for disuse atrophy using a specific type of neuromuscular electrical stimulator (NMES), which transmits an electrical impulse to the skin over selected muscle groups by way of electrodes. Coverage of NMES to treat muscle atrophy is limited to the treatment of patients with disuse atrophy where the nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves and other non-neurological reasons for disuse atrophy. Examples include casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins).

NMES/FES to enhance walking for Spinal Cord Injury (SCI) patients will not be covered for any of the following:
-presence of cardiac pacemakers or cardiac defibulators;
-severe scoliosis or severe osteoporosis;
-irreversible contracture;
-autonomic dysreflexia; or
-skin disease or cancer at area of stimulation.

CPT code 97033: Iontophoresis:
1. This constant attendance modality is a non-invasive mechanism to deliver medication transdermally by the use of electrical stimulation. This modality may be medically reasonable and necessary in certain cases for the patient's condition. For example, in consultation with the referring physician/NPP, it may be determined as the safest intervention to deliver localized analgesia.
2. Iontophoresis will be allowed for treatment of intractable, disabling primary focal hyperhidrosis (ICD-9-CM code 705.21) that has not been responsive to recognized standard therapy. Other less evidence based indication may include tendonitis, bursitis, or adhesive capsulitis if documentation supports need for therapy.
3. Documentation should support its use including dosage of prescribed medications and include the amount, frequency and duration of the treatments.
4. Topical medications used with this modality are not covered under Medicare. The beneficiary may be billed for the medications providing, prior to treatment, the patient has been informed of their responsibility and of the cost of the medication.
5. Iontophoresis is covered for the following ICD09 codes when delivered by means of a '24 hour patch. Only the time spent for the initial application is generally covered. If circumstances require the skills of the clinician for additional visits, documentation must support this and it may be necessary to submit this with the request for a redetermination of the denied claim.

705.21 Disabling primary focal hyperhidrosis
726.0 - 726.91 Adhesive capsulitis of shoulder - exostosis of unspecified site
727.00 Synovitis unspec
727.01 Synovitis other
905.6 Late effect dislocation
905.7 Late effect sprain/strain
905.8 Late effect tendon injury

CPT code 97034 Application of a modality to one or more areas; contrast baths, each 15 minutes
1. Contrast baths are a form of therapeutic heat and cold applied to distal extremities in an alternating pattern.
2. The use of contrast baths is considered medically necessary to desensitize patients to pain. The use of contrast baths may be considered medically necessary for the following:
Documented rheumatoid arthritis or other inflammatory arthritis;
Documented reflex sympathetic dystrophy; or
Documented sprain or strain resulting from an acute injury.
3. Hot/cold baths ordinarily do not require the skills of a licensed clinician. However, the skills, knowledge and judgment of a licensed clinician might be required in the giving of such treatments in a particular case, e.g., where the patient's condition is complicated by circulatory deficiency, areas of desensitization, open wounds, fracture or other complication.
4. Documentation must indicate the presence of these complicating factors for reimbursement of this code. If there are no complicating factors, which would necessitate the skills of a licensed clinician to perform this modality, the modality would be non-covered. However, it could be considered reasonable and necessary for additional visits to give instruction to the patient and/or caregivers in the performance of this modality and to assess the patient's response to the modality.
5. This CPT code is not covered when the services provided are solely hot/cold packs. This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment. This is a constant attendance code requiring direct, one-on-one patient contact by the qualified practitioner. Only the actual time of the qualified practitioner's direct contact with the patient is covered.

CPT code 97035 Application of a modality to one or more areas; ultrasound, each 15 minutes
1. This constant attendance modality delivers deep heat by the use of sound waves reflecting off the tissue interface and is used in the treatment of arthritis, inflammation of periarticular structures, neuromas, to soften adhesive scars and other conditions.
2. The use of ultrasound is considered reasonable and necessary for patients requiring deep heat to a specific area for reduction of pain, spasm, and joint stiffness, and for increased flexibility of muscle, tendons, and ligaments.
3. Ultrasound application is not considered reasonable and necessary for the treatment of asthma, bronchitis, or any other pulmonary condition.
4. Ultrasound with electrical stimulation provided concurrently (e.g., Medcosound, Rich-Mar devices), should be billed as ultrasound (CPT code 97035). Do not bill for both ultrasound and electrical stimulation for the same time period.

Phonophoresis
When phonophoresis is performed, CPT code 97035 should be used.

Simultaneous Electrical Stimulation
Ultrasound with simultaneous electrical stimulation should be billed with CPT code 97035 and any electrical stimulation codes (CPT code 97032, HCPCS code G0281, G0283) should not be used together to reflect ultrasound with simultaneous electrical stimulation.
This modality should be used in conjunction with therapeutic procedures, not as an isolated treatment. If no objective and/or subjective improvement noted after 6 treatments, a change in plan of care (alternative strategies) should be implemented or documentation should support the need for continued use of this modality.

CPT code 97036 Application of a modality to one or more areas; Hubbard tank, each 15 minutes
1. This modality involves the use of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds e.g., ulcers, exfoliative skin conditions.
2. Physician/NPP or therapist supervision of the whirlpool modality is required.
3. It is not medically necessary to have more than one form of hydrotherapy during a visit (CPT codes 97022, 97036, 97113), during the same visit.
4. When medically necessary requires full immersion this should be reflected in the documentation.

CPT code 97039 Unlisted modality (specify type and time if constant attendance)
1. This CPT code should not be used routinely or on a recurring basis.
2. Documentation must support the need for the service provided and document the modality which was provided
3. For all claims submitted with CPT code 97039, a complete narrative description (detailing the service or procedure being performed) must be included on the claim. The plan of care should include information pertaining to the service reported as CPT code 97039, be maintained in the patient's medical record, and made available to Medicare upon request.
4. If the therapy is a constant attendance service, the amount of time should be documented.
5. The coverage of this code will be limited to 1 unit/day.

G. GENERAL GUIDELINES FOR THERAPEUTIC PROCEDURES
CPT codes 97110-97546:

The following clinical guidelines pertain to the specific therapeutic procedures listed below. Please refer to the "ICD-9-CM Codes that Support Medical Necessity" section in this policy for appropriate covered diagnoses to be used with these therapeutic procedures. The types of services provided and the length of treatment should be based on patient presentation (such as acuity) and the clinical judgment of the clinician. Utilization parameters are guidelines and not necessary coverage criteria. All services must be documented and medically necessary.
1. Therapeutic procedures are procedures are intended to reduce impairments and improve function through the application of clinical skills and/or services.
2. Use of these procedures requires that the qualified practitioner have direct (one-on-one) patient contact. In physician/NPPs' offices, the "incident to" provisions apply.

Use of these procedures requires that the qualified provider have direct (one-on-one) patient contact. Only the actual time of direct contact with the patient in providing a service which requires the skills of a clinician is considered for coverage of these services. Supervision of a previously taught exercise or exercise program, patients performing an exercise independently without direct contact by the qualified practitioner, or use of different exercise equipment that does not require the intervention/skills of the qualified provider are not covered. The patient may be in the facility for a longer period of time, but only the time the qualified provider is actually providing direct, one-on-one, patient contact which requires the skills of a clinician is considered covered time for these procedures, and only those minutes of treatment should be recorded.

1. Therapeutic procedures describe several different types of therapeutic intervention. The expected goals documented in the plan of care, affected by the use of each of these procedures, will help define whether these procedures are reasonable and medically necessary. Therefore, since any one or a combination of therapeutic procedure codes may be used in a plan of care, documentation must support the use of each procedure as it relates to a specific therapeutic goal.
2. For CPT code 97110-97112, standard treatment is usually 12 to 18 visits within a 4-6 week period. Documentation supporting the medical necessity for therapeutic procedures beyond the standard treatment frequencies and duration must be available to the Carrier on request. See Change Request 5921.
3. Therapists, or therapy assistants, working together as a "team" to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient. https://www.cms.gov/TherapyServices/02_billing_scenarios.asp
4. A Medicare beneficiary with vision loss may be eligible for rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient's level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical and should be performed by an occupational or physical therapist. (Physical Therapist and Occupational Therapy assistants cannot perform such evaluations.)

Visual Rehabilitation (VR)

Visual rehabilitation is covered under Medicare when the patient has a potential for restoration or improvement of lost functions, is expected to improve significantly within a reasonable and generally predictable amount of time, and there is an appropriately established plan of care. Visual rehabilitation service is not covered if the patient is unable to cooperate in the treatment program or if clear goals are not definable.

Vision impairment ranging from low vision to total blindness may result from a primary eye diagnosis, such as macular degeneration, retinitis pigmentosa or glaucoma, or as a condition secondary to another primary diagnosis, such as diabetes mellitus or acquired immune deficiency syndrome (AIDS).

Medicare beneficiaries with vision loss may be eligible for rehabilitation services designed to improve functioning, by therapy, to improve performance of activities of daily living, including self-care and home management skills. Evaluation of the patient's level of functioning in activities of daily living, followed by implementation of a therapeutic plan of care aimed at safe and independent living, is critical and should be performed by an occupational or physical therapist. (Physical Therapy and Occupational Therapy assistants cannot perform such evaluations.)

Some of the following rehabilitation programs/services for beneficiaries with vision impairment may include Medicare covered therapeutic services:
Mobility;
Activities of Daily Living; and
Other rehabilitation goals that are medically necessary.

The patient must have a potential for restoration or improvement of lost functions, and must be expected to improve significantly within a reasonable and generally predictable amount of time. Rehabilitation services are not covered if the patient is unable to cooperate in the treatment program or if clear goals are not definable. Most rehabilitation is short term and intensive. Maintenance therapy - services required to maintain a level of functioning - is not covered.

H. SPECIFIC GUIDELINES FOR THERAPEUTIC PROCEDURES:

CPT Code 97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility:
1. Therapeutic exercise is performed with a patient either actively, active-assisted, or passively (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening). The exercise may be medically reasonable and necessary for a loss or restriction of joint motion, strength, functional capacity or mobility, which has resulted from a specific disease or injury.
2. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, levels of assistance with exercise, endurance limitations (verified by cardiovascular measures) or flexibility limitations.).
3. If an exercise is instructed to the patient and performed for the purpose of restoring functional strength, range of motion, and flexibility, CPT code 97110 is the appropriate code. For example, a gym ball exercise used for the purpose of increasing the patient's strength should be considered as therapeutic exercise when coding for billing.

CPT Code 97112 Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities:
1. This therapeutic procedure is provided to improve balance, coordination, kinesthetic sense, posture, and proprioception (e.g., proprioceptive neuromuscular facilitation, BAP's boards and desensitization techniques).
2. Documentation must contain objective measurements/ratings of loss of motion, strength, balance, coordination, and/or mobility, e.g., degrees of motion, strength grades, assist for balance and mobility, specific tests for balance and coordination.
3. If an exercise is instructed to the patient and performed for the purpose of restoring functional balance, motor coordination, kinesthetic sense, posture, or proprioception for sitting or standing activities, CPT code 97112 is the appropriate code. For example, a gym ball exercise used for the purpose of improving balance should be considered as neuromuscular reeducation when coding for billing.

CPT Code 97113 Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises:
1. This procedure uses the therapeutic properties of water (e.g., buoyancy, resistance). The procedure may be reasonable and medically necessary for a loss or restriction of joint motion, strength, mobility, or function, which has resulted from a specific disease or injury. Documentation must show objective loss of joint motion, strength, or mobility (e.g., degrees of motion, strength grades, and levels of assistance).
2. Other forms of exercise therapy may be medically necessary in addition to aquatic therapy when the patient cannot perform land-based exercises effectively to treat their condition without first undergoing the aquatic therapy, or when aquatic therapy facilitates progress to land based exercise or increase function. Documentation must be available in the record to support medical necessity.
3. While they do not have to be personally in the water, the physician/NPP/clinician must at a minimum be personally present one-on-one next to the pool for any covered aquatic therapy services
4. The medical necessity for multiple forms of hydrotherapy must be documented in the plan of care and medical records. Documentation must be made available to the Carrier on request.
5. Supervision of a previously taught exercise or exercise program in the aquatic environment or performance of exercise in the aquatic environment that does not require the intervention/skills of the qualified provider is not covered. Performance of exercise in the aquatic environment independently without direct contact by the qualified provider is not covered.
6. If the clinician provides aquatic therapy for more than one patient during the same time period, it is considered group therapy and is covered as such.
7. This code should not be used in situations where no exercise is being performed in the water environment (e.g., debridement of ulcers).
8. Exercises in the water environment to promote overall fitness, flexibility, endurance enhancing, aerobic conditioning, weight reduction, or for maintenance purposes are non-covered.

CPT Code 97116 Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing):
1. This procedure may be medically necessary for training patients with a documented gait deficit whose walking abilities have been impaired by neurological, muscular, or skeletal abnormalities or trauma.
2. This procedure is reasonable and medically necessary when the patient's walking ability as a result of the gait deficit is expected to improve.
3. Repetitive walk-strengthening exercise where a gait deficit does not exist or that does not address gait deficits but focuses on increasing strength and/or increasing endurance in a feeble or unstable patient does not require professional skills and is not considered a skilled therapy service.
4. For Spinal Cord Injury (SCI) patients using a neuromuscular electrical stimulator to enhance the ability to walk see CMS Pub.100-03 Part 3 §160.12.

CPT Code 97124 Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage, and/or tapotement (stroking, compression, percussion):
1. Massage is the application of systemic manipulation to the soft tissues of the body for therapeutic purposes. Although various assistive devices and electrical equipment are available for the purpose of delivering massage, use of the hands is considered the most effective method of application, because palpation can be used as an assessment as well as a treatment tool. Therefore, massage performed with devices or electrical equipment is non-covered.
2. Massage therapy is utilized to decrease spasm, increase relaxation and increase vascular response in muscles and other soft tissues, and may be medically necessary when used in conjunction with other therapeutic procedure on the same day, which in the plan of care is designed to restore muscle function, reduce edema, improve joint motion, or for relief of muscle spasm.
3. Therapeutic massage may be medically necessary as adjunctive treatment to another therapeutic procedure on the same day, which is designed to restore muscle function, reduce edema, improve joint motion, or for relief of muscle spasm.
4. This code is not covered as an isolated treatment.

CPT Code 97139 Unlisted therapeutic procedure (specify)
For all claims submitted for unlisted services or procedures, the following documentation must be submitted:
1. A description of the service or procedure; and,
2. A plan of care including information indicating the medical necessity of the service or procedure

CPT Code 97140 Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
1. Manual traction may be considered reasonable and necessary for cervical dysfunctions such as cervical pain and cervical radiculopathy.
2. Joint Mobilization (peripheral and/or spinal) may be considered reasonable and necessary if restricted or painful joint motion is present and documented. It may be reasonable and necessary as an adjunct to therapeutic exercises when loss of articular motion and flexibility impedes the therapeutic procedure.
3. Myofascial release/soft tissue mobilization, one or more regions, may be reasonable and necessary for treatment of restricted motion of soft tissues in involved extremities, neck, and trunk. Skilled manual techniques (active or passive) are applied to soft tissue to effect changes in the soft tissues, articular structures, neural or vascular systems.
4. Manipulation, which is a high-velocity, low-amplitude thrust technique or Grade V thrust technique, may be reasonable and necessary for treatment of painful spasm or restricted motion in the periphery, extremities or spinal regions.
5. Manual lymphatic drainage/complex decongestive therapy (MLD/CDT)
MLD/CDT is indicated for both primary and secondary lymphedema. Lymphedema in the Medicare population is usually secondary lymphedema, caused by known precipitating factors. Common causes include surgical removal of lymph nodes, fibrosis secondary to radiation, and traumatic injury to the lymphatic system.

Both primary and secondary lymphedemas are chronic and progressive conditions which can be brought under long-term control with effective management. By maintaining control of the lymphedema, patients can:
o restore a normal, or near-normal, shape;
o reduce the potential for complications (e.g., cellulitis, lymphangitis, deformity, injury, fibrosis, lymphangiosarcoma (rare), etc.);
o reduce functional deficits to resume activities of daily living.
MLD/CDT consists of skin care, manual lymph drainage, compression wrapping, and therapeutic exercises. Coverage of MLD/CDT would only be allowed if all of the following conditions have been met:
o there is a physician-documented diagnosis of lymphedema (primary or secondary);
o the patient has documented signs or symptoms of lymphedema;
o the patient or patient caregiver has the ability to understand and comply with the continuation of the treatment regimen at home.
The goal of treatment is to reduce lymphedema of an extremity by routing the fluid to functional pathways, preventing backflow as the new routes become established, and to use the most appropriate methods to maintain such reduction of the extremity after therapy is complete. This therapy involves intensive treatment to reduce the volume by a combination of manual decongestive therapy and serial compression bandaging, followed by an exercise program. Ultimately the plan must be to transfer the responsibility of care from the clinician to management by the patient, patient's family, or patient's caregiver.
o In moderate-severe lymphedema, daily visits may be required.
o Education should be provided to the patient and/or caregiver on the correct application of the compression bandage.
o The therapeutic exercise component for MLD / CDT is covered under CPT code 97110.
MLD/CDT is not covered for:
o conditions reversible by exercise or elevation of the affected area;
o dependent edema related to congestive heart failure or other cardiomyopathies;
o patients who do not have the physical and cognitive abilities, or support systems, to accomplish self-management in a reasonable time;
o continuing treatment for a patient non-compliant with a program for self-management.

CPT code 97124 (massage) is not covered on the same visit as this code.
Supportive Documentation Recommendations for CPT code 97140
- Area(s) being treated
- Soft tissue or joint mobilization technique used
- Objective and subjective measurements of areas treated (may include ROM, capsular end-feel, pain descriptions and ratings,) and effect on function
- For MLD/CDP, supportive documentation should include:
o medical history related to onset, exacerbation and etiology of the lymphedema
o comorbidities
o prior treatment
o cognitive and physical ability of patient and/or caregiver to follow self-management techniques;
o pain/discomfort descriptions and ratings;
o limitation of function related to self-care, mobility, ADLs and/or safety;
o prior level of function;
o limb measurements of affected and unaffected limbs at start of care and periodically throughout treatment;
o description of skin condition, wounds, infected sites, scars.
When the patient and/or caregiver has been instructed in the performance of specific techniques, the performance of these same techniques should not be continued in the clinic setting and counted as minutes of skilled therapy.

CPT Code 97150 Therapeutic procedure(s), group (2 or more individuals):
1. Documentation must be maintained in the medical record identifying the specific treatment technique(s) used in the group, how the treatment technique will restore function, the frequency and duration of the particular group setting, and the treatment goal in the individualized plan. The number of persons in the group must also be furnished. The medical record must be made available upon request.
2. Group therapy consists of simultaneous treatment to two or more patients who may or may not be doing the same activities. Group therapeutic procedures involve constant attendance of the qualified practitioner, but by definition do not require one-on-one contact by them. If the qualified practitioner is dividing attention among the patients, providing only brief, intermittent personal contact, or giving the same instructions to two or more patients at the same time, one (1) unit of CPT code 97150 is appropriate.

Non-covered as group therapy
- Groups directed by a student, therapy aide, rehabilitation technician, nursing aide, recreational therapist, exercise physiologist, or athletic trainer
- Routine (i.e., supportive) groups that are part of a maintenance program, nursing rehabilitation program, or recreational therapy program
- Groups using biofeedback for relaxation
- Viewing videotapes; listening to audiotapes
- Group treatment that does not require the unique skills of a clinician

If group therapy is billed on a given day, it must be listed in the Treatment Note. The minutes of this untimed code must be added to the Total Treatment Time for that day. Further documentation describing the skilled nature of the group session documented in the progress report or the treatment note may assist in supporting the medical necessity of the service.

CPT Code 97530 Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes:
1. These activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination.
2. They require the professional skills of a qualified professional and are designed to address a specific functional need of the patient.
3. These dynamic activities must be part of an active plan of care and directed at a specific outcome.

CPT Code 97532 Development of cognitive skills to improve attention, memory, problem solving, (includes compensatory training) direct (one-on-one) patient contact by the provider, each 15 minutes
1. This procedure may be medically necessary for persons with acquired cognitive impairments resulting from head trauma, or acute neurologic events including cerebrovascular accidents. These services are not indicated for patients with chronic progressive brain conditions without reasonable potential for restoration.
2. These procedure may be medically necessary when included in a patient's certified plan of care aimed at improving or restoring specific functions which were impaired by an identified illness or injury and when expected outcomes that are attainable by the patient are specified in the plan.
3. Similar techniques used in treatment for adults could also be reported as neuromuscular reeducation. However, this procedure differentiates that the intervention is directed at restoring the patient's response to environmental demands while performing particular activities, while neuromuscular reeducation describes training to restore the ability to perform the particular activities.

CPT Code 97533 Sensory integrative techniques to enhance sensory processing and promote adaptive response to environmental demands, direct (one-on-one) patient contact by the provider, each 15 minutes
1. These treatments are performed when a deficit in processing input from one of the sensory systems decreases the patient's ability to make adaptive sensory, motor, and behavioral responses to environmental demands.
2. These patients may demonstrate sensory defensiveness, over-reactivity to environmental stimuli, attention difficulties, and behavioral problems. (CPT Assistant, Vol.11, Issue 12, December 2001)
3. Sensory integrative interventions enhance sensory processing by persons with deficits in sensory systems (e. g., vestibular, proprioceptive, tactile) by increasing their ability to make adaptive sensory, motor, and behavioral responses to environmental demand.
4. Sensory integrative treatments are almost exclusively provided to a pediatric population for responses to environmental demand and are almost exclusively provided for conditions such as autism, developmental disorders, attention deficit hyperactivity disorder, cerebral palsy, and motor apraxia. Similar techniques used in treatment for adults should be coded with CPT code 97112.
5. This procedure is not medically reasonable and necessary when the patient's sensory processing and adaptive responses are not expected to improve.
6. This therapy may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function, and must be utilized with appropriate therapeutic procedures to effect continued improvement.

CPT Code 97535 Self care/home management training (e.g., 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 by provider, each 15 minutes:
1. This therapeutic procedure is intended to provide the patient with instructions in safe and energy efficient ways to navigate the external environment, which may or may not include a work setting. It must be part of an active treatment certified plan of care directed toward specific measurable and meaningful goals that requires the skills of a qualified provider.
2. The patient must have a condition for which training in activities of daily living is reasonable and necessary, and such training must be reasonably expected to restore or improve the functioning of the patient. Documentation must relate the training to expected functional goals that are attainable by the patient.
3. The patient and/or caregiver must have the capacity to learn from instructions.
4. Therapists, or therapy assistants, working together as a "team" to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.
5. It is not appropriate use of this code to cover home instruction of an exercise program. This code should be used for activities of daily living (ADL) and compensatory training for ADL, safety procedures, and instructions in the use of adaptive equipment. This code is not appropriate for instruction on the use of orthotics or assistive devices for gait. If this code is used as therapy, specific documentation should support the use of the code.
6. The medical record should document the distinct goals and service rendered when self-care/home management training is done during the same visit as gait training (CPT code 97116), orthotics fitting or prosthetic training (CPT code 97761).

CPT Code 97537 Community/work reintegration training (e.g., 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 by provider, each 15 minutes:
1. This training may be medically necessary when performed in conjunction with a patient's individual plan of care aimed at improving or restoring specific functions which were impaired by an identified illness or injury and when expected outcomes that are attainable by the patient are specified in the plan.
2. This training is medically necessary only when it requires the professional skills of a qualified practitioner. Generally speaking, qualified practitioner are not required to effect improvement or restoration of function where a patient suffers a temporary loss or reduction of function which could reasonably be expected to improve as the patient gradually resumes normal activities. General activity programs and all activities which are primarily social or diversional in nature will be denied because the professional skills of a qualified practitioner are not required.
3. Services which are related solely to specific employment opportunities, work skills or work settings are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are excluded from coverage by section 1862(a)(1) of the Social Security Act (Medicare Benefit Policy Manual, Pub. 100-2, Chapter 15, Section 220.2, formerly Ref. MCM 2217.B).
4. The patient must have the capacity to learn from instructions.
5. Documentation must relate the training to expected functional goals that are attainable by the patient.

CPT Code 97542 Wheelchair management/propulsion training, each 15 minutes:
1. This procedure is medically necessary only when it requires the professional skills of a supplier to teach the patient wheelchair propulsion and safety techniques, is designed to address specific needs of the patient, and must be part of an active plan of care defining a specific goals attainable by the patient.
2. The patient must have the capacity to learn from instructions.

CPT Code 97750 Physical Performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes:

1. This testing may be reasonable and necessary for patients with neurological or musculoskeletal conditions. These tests and measurements are over and above the usual evaluation services performed. Examples of physical performance tests or measurements include isokinetic testing or Functional Capacity Evaluation (FCE). This code may be used for the 6-minute walk test, with a computerized report of the patient's oxygen saturation levels with increasing stress levels, performed under a PT or OT plan of care on pulmonary rehabilitation patients.
2. It is not reasonable and necessary for the test to be performed and billed on a routine basis (e.g., monthly or instead of billing a reevaluation) or to be routinely performed on all patients treated.
3. CPT code 97001 or CPT code 97002 is not covered on the same day as CPT code 97750.
4. This service requires direct one-on-one patient contact by the clinician billing the service to Medicare.

The therapy evaluation and re-evaluation codes are for a comprehensive review of the patient including, but not limited to, history, systems review, current clinical findings, establishment of a therapy diagnosis, and estimation of the prognosis and determination and/or revision of further treatment. CPT 97750 is intended to focus on patient performance of a specific activity or group of activities (CPT Assistant, December 2003).

CPT Code 97755 Assistive technology assessment (e.g., to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact by provider, with written report, each 15 minutes
1. This procedure is medically necessary only when it requires the skills of a qualified practitioner, is designed to address specific needs of the patient, and must be part of an active plan of care directed at a specific outcome for assessment of mobility and seating systems that require high level adaptations, not for routine seating and mobility systems (e.g. manual/power wheelchair evaluations).
2. The qualified practitioner must perform an assessment for the suitability and benefits of acquiring any assistive technology device or equipment that will help restore, augment, or compensate for existing functional ability in the patient (i.e. provision of large amounts of rehabilitative engineering).

CPT code 97760 - Orthotic(s) Management and Training
CPT code 97760 is not covered when performed with CPT code 97116.
Customized Orthotics
The four major components of a customized orthotic are: Assessment, Fabrication, Fitting, and Training.

1. Under Medicare there are provisions for coverage and reimbursement for orthotics under the HCPCS Level II Coding System. Orthotics are generally divided into prefabricated and customized. Coverage in the LCD parallels this division as follows:
Prefabricated Orthotics
Prefabricated orthotics are defined as commercial, off-the-shelf, non-individualized, etc. Minor modifications to a prefabricated orthotic do not constitute a customized orthotic Coverage for the following services are covered under the respective HCPCS 'L' code:
Evaluating the patient
Taking measurements
Making modifications
Follow-up visits
Making adjustments
2. Coverage under the respective HCPCS 'L' code is for a 90 day global period; therefore CPT code 97760 is not covered for a prefabricated orthotic.
3. During the '90-day' global period, medically necessary interventions (e.g. ADL retraining, neuromuscular re-ed, etc.) are covered under each respective CPT code.
4. The Assessment, Fabrication, and Fitting are considered part of the "Management" of a customized orthotic. As noted above and referenced in the CPT code definition, the management, under Medicare, is covered within the respective HCPCS L-code NOT within CPT code 97760.
5. The Training component is the covered, one to one, time within CPT code 97760
Training as appropriate of customized orthotic devices are used to enhance the performance of tasks or movements, support weak or ineffective joints or muscles, reduce/correct joint limitations/deformities, and/or protect body parts from injury. The orthotics are often used in conjunction with therapeutic exercise, functional training, and other interventions and should be selected in the context of the patient's need.
6. The clinician targets the problems in performance of movements or tasks and selects the most appropriate device or equipment, then fits the device, and trains the patient and/or caregivers in its use and application. The goal is for the patient to function at a higher level by decreasing functional limitations or the risk of further functional limitations.
7. Repetitive range of motion prior to placing a customized orthotic/positioner to maintain the range of motion is not reasonable and necessary when the therapeutic intent is to primarily maintain range of motion within a chronic condition.
8. Additional visits made to continue to assess for the customized orthotic need to be clarified to establish medical necessity. The customized orthotic should be available in a timely fashion. The customized orthotic/positioning program is to be set up and then handed over to the restorative nursing staff or caregiver for follow through. Neither monitoring nor ongoing visits for increasing wearing time are covered unless problems have been observed.
9. Upon issuing the custom fabricated orthotic, staff/caregiver instruction should be done simultaneously. Ongoing visits by the clinician to apply the device would be considered monitoring. Once the initial fit is established, any further visits should be used for specific documented problems and modifications that require skilled services are covered under CPT code 97762.

If this code is used for the treatment of a lower extremity, CPT code 97116 and CPT code 97535 are not covered on the same treatment day. If this code is used for the treatment of an upper extremity, CPT code 97535 is not covered on the same treatment day.

Coverage under CPT code 97760 is for custom fabricated seating and posturing supports. 'Custom fabricated' means the item is individually made for a patient using: a) a plaster model of the patient, b) computer generated model, or c) detached measurements of the patient used to create a carved foam custom fabricated support. Documentation should include parameters used in custom fabrication. If this code is used for the treatment of an upper extremity, CPT code 97535 is not covered on the same treatment day.

Note: The following items are included in the DMERC reimbursement for an orthosis within 90 days of delivery of the orthosis and, therefore, are not separately billable to Medicare Part B:
1. Evaluation of the orthosis
2. Fitting of the orthosis
3. Cost of base component parts and labor contained in HCPCS base codes
4. Repairs due to normal wear or tear
5. Adjustments of the orthosis or the orthotic component made when fitting the orthotic or component when the adjustments are not necessitated by changes in the patient's functional abilities.

CPT Code 97761 Prosthetic training, upper and/or lower extremities, each 15 minutes:
The medical record should document the distinct goals and service rendered when prosthetic training for a lower extremity is done during the same visit as gait training (CPT code 97116) or self care/home management training done during the same visit as management training (CPT code 97535).

Note: The following items are included in the DMERC reimbursement for a prosthesis within 90 days of delivery of the prosthesis and, therefore, are not separately billable to Medicare Part B:
1. Evaluation of the residual limb and/or gait
2. Fitting of the prosthesis
3. Cost of base component parts and labor contained in HCPCS base codes
4. Repairs due to normal wear or tear
5. Adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component when the adjustments are not necessitated by changes in the residual limb or the patient's functional abilities.
6. If this code is used for the treatment of a lower extremity, CPT code 97116 and CPT code 97535 are not covered on the same treatment day.
7. If this code is used for the treatment of an upper extremity, CPT code 97535 is not covered on the same treatment day.

CPT code 97762 - Checkout for Orthotic/Prosthetic Use, established patient
These assessments are intended for established patients who have already received their orthotic or prosthetic device.
1. P & O checkout assessments may be medically necessary when a device is newly issued, re-issued or modified.
2. These assessments may be medically necessary when patients experience loss of function directly related to the orthotic or prosthetic device (e.g., pain, skin breakdown, or falls).
3. These assessments may not be considered reasonable and necessary when a device is newly issued or when a device is reissued or replaced after normal wear and no modifications are needed.
4. Documentation of the need for more than 60 minutes of time must be available on request.
5. Per CCI CPT code 97002 is not covered on the same date as CPT code 97762.

CPT Code 97799 Unlisted physical medicine/rehabilitation service or procedure:
For all claims submitted for unlisted services or procedures, the following documentation must be submitted:
1. A description of the service or procedure; and,
2. A plan of care including information indicating the medical necessity of the service or procedure

CPT Code 94667 - 94668 Manipulation chest wall, such as cupping, percussing, and vibration to facilitate lung function

J. NOT COVERED

CPT code 97810 Acupuncture, one or more needles; without electrical stimulation, initial 15 minutes or personal one-on-one contact with the patient

CPT code 97811 each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)

CPT code 97813 Acupuncture, one or more needles; with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient

CPT code 97814 each additional 15 minutes of personal one-on-one contact with the patient, with re-insertion of needle(s)

The following services are not covered and may not be billed with a therapy code:
1. Services not performed by or under the direct supervision of the clinician are not covered.
2. Services billed to Medicare Part B, performed by persons other than employees of the qualified practitioner practice are not covered.
3. Services not relating to a certified plan of care that was established by the qualified practitioner or by the physician/NPP before treatment began are not covered.
4. Services billed to Medicare Part B that are not furnished in the qualified practitioner's office or in the patient's home are not covered.
5. Physical or occupational therapy services that do not require the professional skills of a qualified physical or occupational therapist to perform or supervise and therefore are not covered.
6. CPT code 0020T - Extracorporeal shock wave therapy; involving musculoskeletal system involving plantar fasci
7. CPT code 0029T - Treatment(s) for incontinence, pulsed magnetic neuromodulation, per day
8. CPT code 97001 - 97004 - An evaluation by a qualified practitioner is non-covered when the evaluation is for a non-covered service (e.g. wheelchair ramp)
9. A visit for the sole purpose of wheelchair management (i.e. assessment) does not require the billing of CPT code 97001 and CPT code 97002 but instead is covered under CPT code 97542. See CPT code 97542 for further coverage.
10. Presurgical evaluations for the purpose of HEP and assistive device instruction are not covered. This may include but not limited to crutch-walking, donning/doffing of post-surgical immobilizers and/or splints.
11. Services which are related solely to specific employment opportunities (i.e., on-the-job training, work skills, or work settings) are not reasonable and necessary for the diagnosis and treatment of an illness or injury and are not covered.
12. The educational component of treatment is included in the service described by the specific CPT code; therefore there is no separate coverage for education
13. Work hardening/conditioning; initial 2 hours (CPT code 97545) and Work hardening/conditioning; initial 2 hours (CPT code 97546) are not covered by National Regulations.

NOTE: These four codes (CPT codes 97810, 97811, 97813, and 97814) are not covered services by Medicare. Based on the National Coverage Determination Manual, Pub. 100-3, Section 30.3.

The following therapies are not covered and may not be billed with any therapy code:

1. Hot/cold packs (including Aquamed) applied in the absence of associated procedures or modalities, or used alone to reduce discomfort are considered not to require the unique skills of a qualified practitioner.
2 Exercises to promote overall fitness, flexibility, endurance enhancing, aerobic conditioning, weight reduction, and maintenance exercises to maintain range of motion and/or strength are non-covered.
3. Passive exercises not related to restoring specific loss of function are non-covered.
4. Vertebral axial decompression is performed for symptomatic relief of pain associated with lumbar disk problems. The treatment combines pelvic and/or cervical traction connected to a special table that permits the traction application. There is insufficient scientific data to support the benefits of this technique. Therefore, VAX-D is not covered by Medicare.
5. CPT code 97112 is not covered for biofeedback therapy. This may be billed using CPT 90901 - Biofeedback training by any modality regulations is in another LCD.
6. Athletic training.
7. Physical medicine and rehabilitation services are not covered when the documentation indicates that a patient has attained the therapy goals or has reached the point where no further significant practical improvement can be expected. The skills of the clinician are not required to maintain function.
8. Enhancing already evident/existing functional status (i.e. basic ADLs have been met) is not reasonable and necessary; therefore noncovered.
9. Physical medicine and rehabilitation services are not covered by Medicare to treat Skilled Nursing Facility patients whose care can safely and effectively be rendered by the Skilled Nursing Facility's trained qualified professional staff.
10. Physical medicine and rehabilitation services are not covered when a patient suffers a temporary loss or reduction of function and could reasonably be expected to improve spontaneously without the services of the clinician. For example, the patient recovering from a short hospital stay for pneumonia may need only time to regain their strength and function.
11. Physical medicine and rehabilitation services provided to identify patients who might need or benefit from physical therapy intervention are not covered.
12. Physical medicine and rehabilitation services which are duplicative of other concurrent rehabilitation services are not covered.
13. HCPCS G0237 - Therapeutic procedures to increase strength or endurance of respiratory muscles, face-to-face, one-on-one, each 15 minutes (including monitoring)

Microamperage E-stimulation (MENS) has not been proven effective and will be denied as such. If MENS therapy is billed to Medicare for a denial, such as in cases of supplemental coverage, qualified practitioners should bill using CPT code 97799, placing "MENS therapy" in Item 19 on the CMS 1500 form or equivalent electronic field. An Advance Beneficiary Notice (ABN) should be obtained when MENS is utilized.

Vertebral Axial Decompression (VAX-D®)
As noted in Medicare National Coverage Determination Manual, Pub. 100-3, Section 160.11, Vertebral Axial Decompression (VAX-D®) is not covered by Medicare. Medicare notes that there is insufficient scientific data to support a finding of significant benefits of this technique. If billing for a denial for the provision of this service, you must use CPT code 97799, unlisted physical medicine/rehabilitation service or procedure, and enter "VAX-D®" in Item 19 on the CMS 1500 claim form, or electronic equivalent. An Advance Beneficiary Notice (ABN) should be obtained when VAX-D® is utilized. DO NOT bill using 64722, decompression, unspecified nerves, or CPT code 97012, application of modality.

MedX or SPINEX® or DRX9000 TM
MedX or SPINEX® or DRX9000 TM treatments are a non-covered, and the services will be denied as not proven effective. Use procedure code 97799, unlisted physical medicine/rehabilitation service or procedure, and enter "MedX" or "SPINEX®" or "DRX90000 TM" in Item 19 on the CMS 1500 claim form, or electronic equivalent. An Advance Beneficiary Notice (ABN) should be obtained when MedX or SPINEX® are utilized.

Monochromatic infrared photo energy (MIRE TM), anodyne, anodyne therapy, or similar devices are NOT covered services. Use CPT code 97799, Unlisted physical medicine/rehabilitation service or procedure, and enter "monochromatic infrared photo energy (MIRE TM), anodyne, anodyne therapy, or similar devices" in Item 19 on the CMS 1500 claim form, or in the equivalent field on the electronic claims. This service will be denied as not proven effective. An Advance Beneficiary Notice (ABN) should be obtained when MIRE is utilized.

Other similar devices will also be denied as not proven effective. Qualified practitioners may not bill the beneficiary unless they previously informed the beneficiary that this service will be denied by Medicare and has obtained his/her signature on a valid Advance Beneficiary Notice (ABN) before providing this service.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

NOTE: for CPT codes 97597, 97598, 97605, 97606, G0281 and G0329 See LCD L28572 - GSURG-051

97001	PHYSICAL THERAPY EVALUATION
97002	PHYSICAL THERAPY RE-EVALUATION
97003	OCCUPATIONAL THERAPY EVALUATION
97004	OCCUPATIONAL THERAPY RE-EVALUATION
97010	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; HOT OR COLD PACKS
97012	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; TRACTION, MECHANICAL
97016	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; VASOPNEUMATIC DEVICES
97018	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; PARAFFIN BATH
97022	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; WHIRLPOOL
97024	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; DIATHERMY (EG, MICROWAVE)
97026	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; INFRARED
97028	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRAVIOLET
97032	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ELECTRICAL STIMULATION (MANUAL), EACH 15 MINUTES
97033	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; IONTOPHORESIS, EACH 15 MINUTES
97034	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; CONTRAST BATHS, EACH 15 MINUTES
97035	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; ULTRASOUND, EACH 15 MINUTES
97036	APPLICATION OF A MODALITY TO 1 OR MORE AREAS; HUBBARD TANK, EACH 15 MINUTES
97039	UNLISTED MODALITY (SPECIFY TYPE AND TIME IF CONSTANT ATTENDANCE)
97110	THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; THERAPEUTIC EXERCISES TO DEVELOP STRENGTH AND ENDURANCE, RANGE OF MOTION AND FLEXIBILITY
97112	THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; NEUROMUSCULAR REEDUCATION OF MOVEMENT, BALANCE, COORDINATION, KINESTHETIC SENSE, POSTURE, AND/OR PROPRIOCEPTION FOR SITTING AND/OR STANDING ACTIVITIES
97113	THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; AQUATIC THERAPY WITH THERAPEUTIC EXERCISES
97116	THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; GAIT TRAINING (INCLUDES STAIR CLIMBING)
97124	THERAPEUTIC PROCEDURE, 1 OR MORE AREAS, EACH 15 MINUTES; MASSAGE, INCLUDING EFFLEURAGE, PETRISSAGE AND/OR TAPOTEMENT (STROKING, COMPRESSION, PERCUSSION)
97139	UNLISTED THERAPEUTIC PROCEDURE (SPECIFY)
97140	MANUAL THERAPY TECHNIQUES (EG, MOBILIZATION/ MANIPULATION, MANUAL LYMPHATIC DRAINAGE, MANUAL TRACTION), 1 OR MORE REGIONS, EACH 15 MINUTES
97150	THERAPEUTIC PROCEDURE(S), GROUP (2 OR MORE INDIVIDUALS)
97530	THERAPEUTIC ACTIVITIES, DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER (USE OF DYNAMIC ACTIVITIES TO IMPROVE FUNCTIONAL PERFORMANCE), EACH 15 MINUTES
97532	DEVELOPMENT OF COGNITIVE SKILLS TO IMPROVE ATTENTION, MEMORY, PROBLEM SOLVING (INCLUDES COMPENSATORY TRAINING), DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER, EACH 15 MINUTES
97533	SENSORY INTEGRATIVE TECHNIQUES TO ENHANCE SENSORY PROCESSING AND PROMOTE ADAPTIVE RESPONSES TO ENVIRONMENTAL DEMANDS, DIRECT (ONE-ON-ONE) PATIENT CONTACT BY THE PROVIDER, 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 BY PROVIDER, 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 BY PROVIDER, EACH 15 MINUTES
97542	WHEELCHAIR MANAGEMENT (EG, ASSESSMENT, FITTING, TRAINING), EACH 15 MINUTES
97597	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, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; FIRST 20 SQ CM OR LESS
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, EXUDATE, DEBRIS, BIOFILM), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, USE OF A WHIRLPOOL, WHEN PERFORMED AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION, TOTAL WOUND(S) SURFACE AREA; EACH ADDITIONAL 20 SQ CM, OR PART THEREOF (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
97605	NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA LESS THAN OR EQUAL TO 50 SQUARE CENTIMETERS
97606	NEGATIVE PRESSURE WOUND THERAPY (EG, VACUUM ASSISTED DRAINAGE COLLECTION), INCLUDING TOPICAL APPLICATION(S), WOUND ASSESSMENT, AND INSTRUCTION(S) FOR ONGOING CARE, PER SESSION; TOTAL WOUND(S) SURFACE AREA GREATER THAN 50 SQUARE CENTIMETERS
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 BY PROVIDER, WITH WRITTEN REPORT, EACH 15 MINUTES
97760	ORTHOTIC(S) MANAGEMENT AND TRAINING (INCLUDING ASSESSMENT AND FITTING WHEN NOT OTHERWISE REPORTED), UPPER EXTREMITY(S), LOWER EXTREMITY(S) AND/OR TRUNK, EACH 15 MINUTES
97761	PROSTHETIC TRAINING, UPPER AND/OR LOWER EXTREMITY(S), EACH 15 MINUTES
97762	CHECKOUT FOR ORTHOTIC/PROSTHETIC USE, ESTABLISHED PATIENT, EACH 15 MINUTES
97799	UNLISTED PHYSICAL MEDICINE/REHABILITATION SERVICE OR PROCEDURE
G0281	ELECTRICAL STIMULATION, (UNATTENDED), TO ONE OR MORE AREAS, FOR CHRONIC STAGE III AND STAGE IV PRESSURE ULCERS, ARTERIAL ULCERS, DIABETIC ULCERS, AND VENOUS STATSIS ULCERS NOT DEMONSTRATING MEASURABLE SIGNS OF HEALING AFTER 30 DAYS OF CONVENTIONAL CARE, AS PART OF A THERAPY PLAN OF CARE
G0283	ELECTRICAL STIMULATION (UNATTENDED), TO ONE OR MORE AREAS FOR INDICATION(S) OTHER THAN WOUND CARE, AS PART OF A THERAPY PLAN OF CARE
G0329	ELECTROMAGNETIC THERAPY, 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

ICD-9 Codes that Support Medical Necessity

The following ICD-9 codes are for all CPT codes listed in this LCD except CPT code 97033 - Iontophoresis; The ICD-9 codes that are covered for CPT code 97033 follow this list
Note: ICD-9 codes must be coded to the highest level of specificity.

053.11	GENICULATE HERPES ZOSTER
053.14	HERPES ZOSTER MYELITIS
138	LATE EFFECTS OF ACUTE POLIOMYELITIS
270.0	DISTURBANCES OF AMINO-ACID TRANSPORT
274.00 - 274.9	GOUTY ARTHROPATHY, UNSPECIFIED - GOUT UNSPECIFIED
295.00 - 295.55	SIMPLE TYPE SCHIZOPHRENIA UNSPECIFIED STATE - LATENT SCHIZOPHRENIA IN REMISSION
295.85	OTHER SPECIFIED TYPES OF SCHIZOPHRENIA IN REMISSION
306.0	MUSCULOSKELETAL MALFUNCTION ARISING FROM MENTAL FACTORS
332.0 - 332.1	PARALYSIS AGITANS - SECONDARY PARKINSONISM
333.0 - 333.91	OTHER DEGENERATIVE DISEASES OF THE BASAL GANGLIA - STIFF-MAN SYNDROME
334.0 - 334.9	FRIEDREICH'S ATAXIA - SPINOCEREBELLAR DISEASE UNSPECIFIED
335.0 - 335.9	WERDNIG-HOFFMANN DISEASE - ANTERIOR HORN CELL DISEASE UNSPECIFIED
336.0 - 336.8	SYRINGOMYELIA AND SYRINGOBULBIA - OTHER MYELOPATHY
337.20 - 337.29	REFLEX SYMPATHETIC DYSTROPHY UNSPECIFIED - REFLEX SYMPATHETIC DYSTROPHY OF OTHER SPECIFIED SITE
338.21	CHRONIC PAIN DUE TO TRAUMA
338.29	OTHER CHRONIC PAIN
338.4	CHRONIC PAIN SYNDROME
340	MULTIPLE SCLEROSIS
341.1 - 341.9	SCHILDER'S DISEASE - DEMYELINATING DISEASE OF CENTRAL NERVOUS SYSTEM UNSPECIFIED
342.00 - 342.92	FLACCID HEMIPLEGIA AND HEMIPARESIS AFFECTING UNSPECIFIED SIDE - UNSPECIFIED HEMIPLEGIA AND HEMIPARESIS AFFECTING NONDOMINANT SIDE
343.0 - 343.9	CONGENITAL DIPLEGIA - INFANTILE CEREBRAL PALSY UNSPECIFIED
344.00 - 344.9	QUADRIPLEGIA UNSPECIFIED - PARALYSIS UNSPECIFIED
348.1	ANOXIC BRAIN DAMAGE
351.0	BELL'S PALSY
351.9	FACIAL NERVE DISORDER UNSPECIFIED
353.0 - 353.9	BRACHIAL PLEXUS LESIONS - UNSPECIFIED NERVE ROOT AND PLEXUS DISORDER
354.0 - 354.9	CARPAL TUNNEL SYNDROME - MONONEURITIS OF UPPER LIMB UNSPECIFIED
355.0 - 355.9	LESION OF SCIATIC NERVE - MONONEURITIS OF UNSPECIFIED SITE
356.0 - 356.9	HEREDITARY PERIPHERAL NEUROPATHY - UNSPECIFIED IDIOPATHIC PERIPHERAL NEUROPATHY
357.0 - 357.9	ACUTE INFECTIVE POLYNEURITIS - UNSPECIFIED INFLAMMATORY AND TOXIC NEUROPATHIES
358.00 - 358.9	MYASTHENIA GRAVIS WITHOUT (ACUTE) EXACERBATION - MYONEURAL DISORDERS UNSPECIFIED
359.0 - 359.9	CONGENITAL HEREDITARY MUSCULAR DYSTROPHY - MYOPATHY UNSPECIFIED
368.41	SCOTOMA INVOLVING CENTRAL AREA
368.45 - 368.47	GENERALIZED VISUAL FIELD CONTRACTION OR CONSTRICTION - HETERONYMOUS BILATERAL FIELD DEFECTS
369.00 - 369.9	BLINDNESS OF BOTH EYES IMPAIRMENT LEVEL NOT FURTHER SPECIFIED - UNSPECIFIED VISUAL LOSS
386.10	PERIPHERAL VERTIGO UNSPECIFIED
386.11	BENIGN PAROXYSMAL POSITIONAL VERTIGO
386.12	VESTIBULAR NEURONITIS
386.2	VERTIGO OF CENTRAL ORIGIN
386.34	TOXIC LABYRINTHITIS
386.51 - 386.56	HYPERACTIVE LABYRINTH UNILATERAL - LOSS OF LABYRINTHINE REACTIVITY BILATERAL
386.9	UNSPECIFIED VERTIGINOUS SYNDROMES AND LABYRINTHINE DISORDERS
413.9	OTHER AND UNSPECIFIED ANGINA PECTORIS
430	SUBARACHNOID HEMORRHAGE
431	INTRACEREBRAL HEMORRHAGE
432.0 - 432.9	NONTRAUMATIC EXTRADURAL HEMORRHAGE - UNSPECIFIED INTRACRANIAL HEMORRHAGE
436	ACUTE BUT ILL-DEFINED CEREBROVASCULAR DISEASE
438.0 - 438.53	COGNITIVE DEFICITS - OTHER PARALYTIC SYNDROME BILATERAL
438.81 - 438.84	APRAXIA CEREBROVASCULAR DISEASE - ATAXIA
457.0	POSTMASTECTOMY LYMPHEDEMA SYNDROME
457.1	OTHER LYMPHEDEMA
459.31	CHRONIC VENOUS HYPERTENSION WITH ULCER
459.33	CHRONIC VENOUS HYPERTENSION WITH ULCER AND INFLAMMATION
482.0 - 482.9	PNEUMONIA DUE TO KLEBSIELLA PNEUMONIAE - BACTERIAL PNEUMONIA UNSPECIFIED
484.1 - 486	PNEUMONIA IN CYTOMEGALIC INCLUSION DISEASE - PNEUMONIA ORGANISM UNSPECIFIED
487.0 - 488.19	INFLUENZA WITH PNEUMONIA - INFLUENZA DUE TO IDENTIFIED 2009 H1N1 INFLUENZA VIRUS WITH OTHER MANIFESTATIONS
490 - 491.9	BRONCHITIS NOT SPECIFIED AS ACUTE OR CHRONIC - UNSPECIFIED CHRONIC BRONCHITIS
492.0 - 492.8	EMPHYSEMATOUS BLEB - OTHER EMPHYSEMA
493.00	EXTRINSIC ASTHMA UNSPECIFIED
493.11	INTRINSIC ASTHMA WITH STATUS ASTHMATICUS
493.20	CHRONIC OBSTRUCTIVE ASTHMA UNSPECIFIED
493.21	CHRONIC OBSTRUCTIVE ASTHMA WITH STATUS ASTHMATICUS
493.90	ASTHMA UNSPECIFIED
493.91	ASTHMA UNSPECIFIED TYPE WITH STATUS ASTHMATICUS
495.0 - 495.9	FARMERS' LUNG - UNSPECIFIED ALLERGIC ALVEOLITIS AND PNEUMONITIS
496	CHRONIC AIRWAY OBSTRUCTION NOT ELSEWHERE CLASSIFIED
500	COAL WORKERS' PNEUMOCONIOSIS
501	ASBESTOSIS
502	PNEUMOCONIOSIS DUE TO OTHER SILICA OR SILICATES
503	PNEUMOCONIOSIS DUE TO OTHER INORGANIC DUST
504	PNEUMONOPATHY DUE TO INHALATION OF OTHER DUST
505	PNEUMOCONIOSIS UNSPECIFIED
506.0 - 506.9	BRONCHITIS AND PNEUMONITIS DUE TO FUMES AND VAPORS - UNSPECIFIED RESPIRATORY CONDITIONS DUE TO FUMES AND VAPORS
507.0 - 507.8	PNEUMONITIS DUE TO INHALATION OF FOOD OR VOMITUS - PNEUMONITIS DUE TO OTHER SOLIDS AND LIQUIDS
508.0 - 508.1	ACUTE PULMONARY MANIFESTATIONS DUE TO RADIATION - CHRONIC AND OTHER PULMONARY MANIFESTATIONS DUE TO RADIATION
508.8 - 508.9	RESPIRATORY CONDITIONS DUE TO OTHER SPECIFIED EXTERNAL AGENTS - RESPIRATORY CONDITIONS DUE TO UNSPECIFIED EXTERNAL AGENT
510.0 - 510.9	EMPYEMA WITH FISTULA - EMPYEMA WITHOUT FISTULA
511.0 - 511.9	PLEURISY WITHOUT EFFUSION OR CURRENT TUBERCULOSIS - UNSPECIFIED PLEURAL EFFUSION
512.0	SPONTANEOUS TENSION PNEUMOTHORAX
512.1	IATROGENIC PNEUMOTHORAX
513.0 - 515	ABSCESS OF LUNG - POSTINFLAMMATORY PULMONARY FIBROSIS
516.0	PULMONARY ALVEOLAR PROTEINOSIS
516.1	IDIOPATHIC PULMONARY HEMOSIDEROSIS
516.2	PULMONARY ALVEOLAR MICROLITHIASIS
516.8	OTHER SPECIFIED ALVEOLAR AND PARIETOALVEOLAR PNEUMONOPATHIES
516.9	UNSPECIFIED ALVEOLAR AND PARIETOALVEOLAR PNEUMONOPATHY
517.1 - 517.8	RHEUMATIC PNEUMONIA - LUNG INVOLVEMENT IN OTHER DISEASES CLASSIFIED ELSEWHERE
518.0 - 518.3	PULMONARY COLLAPSE - PULMONARY EOSINOPHILIA
518.6 - 518.89	ALLERGIC BRONCHOPULMONARY ASPERGILLIOSIS - OTHER DISEASES OF LUNG NOT ELSEWHERE CLASSIFIED
519.00 - 519.9	TRACHEOSTOMY COMPLICATION UNSPECIFIED - UNSPECIFIED DISEASE OF RESPIRATORY SYSTEM
524.60 - 524.64	TEMPOROMANDIBULAR JOINT DISORDERS UNSPECIFIED - TEMPOROMANDIBULAR JOINT SOUNDS ON OPENING AND/OR CLOSING THE JAW
618.83	PELVIC MUSCLE WASTING
681.00 - 681.11	UNSPECIFIED CELLULITIS AND ABSCESS OF FINGER - ONYCHIA AND PARONYCHIA OF TOE
682.2 - 682.7	CELLULITIS AND ABSCESS OF TRUNK - CELLULITIS AND ABSCESS OF FOOT EXCEPT TOES
696.0	PSORIATIC ARTHROPATHY
707.00 - 707.9	PRESSURE ULCER, UNSPECIFIED SITE - CHRONIC ULCER OF UNSPECIFIED SITE
709.2	SCAR CONDITIONS AND FIBROSIS OF SKIN
710.0 - 719.99	SYSTEMIC LUPUS ERYTHEMATOSUS - UNSPECIFIED JOINT DISORDER OF MULTIPLE SITES
720.0 - 724.9	ANKYLOSING SPONDYLITIS - OTHER UNSPECIFIED BACK DISORDERS
725 - 729.99	POLYMYALGIA RHEUMATICA - OTHER DISORDERS OF SOFT TISSUE
730.00 - 739.9	ACUTE OSTEOMYELITIS SITE UNSPECIFIED - NONALLOPATHIC LESIONS OF ABDOMEN AND OTHER SITES NOT ELSEWHERE CLASSIFIED
754.1	CONGENITAL MUSCULOSKELETAL DEFORMITIES OF STERNOCLEIDOMASTOID MUSCLE
755.30 - 755.38	UNSPECIFIED REDUCTION DEFORMITY OF LOWER LIMB CONGENITAL - LONGITUDINAL DEFICIENCY TARSALS OR METATARSALS COMPLETE OR PARTIAL (WITH OR WITHOUT INCOMPLETE PHALANGEAL DEFICIENCY)
755.61 - 755.64	COXA VALGA CONGENITAL - CONGENITAL DEFORMITY OF KNEE (JOINT)
781.0 - 781.99	ABNORMAL INVOLUNTARY MOVEMENTS - OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEMS
782.2 - 782.3	LOCALIZED SUPERFICIAL SWELLING MASS OR LUMP - EDEMA
783.3	FEEDING DIFFICULTIES AND MISMANAGEMENT
784.61	ALEXIA AND DYSLEXIA
784.69	OTHER SYMBOLIC DYSFUNCTION
786.4	ABNORMAL SPUTUM
786.59	OTHER CHEST PAIN
787.60 - 787.63	FULL INCONTINENCE OF FECES - FECAL URGENCY
788.30 - 788.33	URINARY INCONTINENCE UNSPECIFIED - MIXED INCONTINENCE (MALE) (FEMALE)
788.38	OVERFLOW INCONTINENCE
799.3	DEBILITY UNSPECIFIED
799.4	CACHEXIA
805.00 - 809.1	CLOSED FRACTURE OF CERVICAL VERTEBRA UNSPECIFIED LEVEL - FRACTURE OF BONES OF TRUNK OPEN
810.00 - 819.1	CLOSED FRACTURE OF CLAVICLE UNSPECIFIED PART - MULTIPLE OPEN FRACTURES INVOLVING BOTH UPPER LIMBS AND UPPER LIMB WITH RIB(S) AND STERNUM
820.00 - 829.1	FRACTURE OF UNSPECIFIED INTRACAPSULAR SECTION OF NECK OF FEMUR CLOSED - FRACTURE OF UNSPECIFIED BONE OPEN
830.0 - 839.9	CLOSED DISLOCATION OF JAW - OPEN DISLOCATION MULTIPLE AND ILL-DEFINED SITES
840.0 - 848.9	ACROMIOCLAVICULAR (JOINT) (LIGAMENT) SPRAIN - UNSPECIFIED SITE OF SPRAIN AND STRAIN
850.0 - 854.19	CONCUSSION WITH NO LOSS OF CONSCIOUSNESS - INTRACRANIAL INJURY OF OTHER AND UNSPECIFIED NATURE WITH OPEN INTRACRANIAL WOUND WITH CONCUSSION UNSPECIFIED
885.0 - 885.1	TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF THUMB (COMPLETE)(PARTIAL) COMPLICATED
886.0 - 886.1	TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF OTHER FINGER(S) (COMPLETE) (PARTIAL) COMPLICATED
887.0 - 887.7	TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) UNILATERAL BELOW ELBOW WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF ARM AND HAND (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED
896.0 - 896.3	TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) UNILATERAL WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) BILATERAL COMPLICATED
897.0 - 897.7	TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) UNILATERAL BELOW KNEE WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF LEG(S) (COMPLETE) (PARTIAL) BILATERAL (ANY LEVEL) COMPLICATED
905.1 - 905.9	LATE EFFECT OF FRACTURE OF SPINE AND TRUNK WITHOUT SPINAL CORD LESION - LATE EFFECT OF TRAUMATIC AMPUTATION
923.00 - 923.9	CONTUSION OF SHOULDER REGION - CONTUSION OF UNSPECIFIED PART OF UPPER LIMB
924.00 - 924.4	CONTUSION OF THIGH - CONTUSION OF MULTIPLE SITES OF LOWER LIMB
926.0 - 926.9	CRUSHING INJURY OF EXTERNAL GENITALIA - CRUSHING INJURY OF UNSPECIFIED SITE OF TRUNK
927.00 - 927.9	CRUSHING INJURY OF SHOULDER REGION - CRUSHING INJURY OF UNSPECIFIED SITE OF UPPER LIMB
928.00 - 928.9	CRUSHING INJURY OF THIGH - CRUSHING INJURY OF UNSPECIFIED SITE OF LOWER LIMB
929.0	CRUSHING INJURY OF MULTIPLE SITES NOT ELSEWHERE CLASSIFIED
941.20 - 941.39	BLISTERS WITH EPIDERMAL LOSS DUE TO BURN (SECOND DEGREE) OF FACE AND HEAD UNSPECIFIED SITE - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES (EXCEPT WITH EYE) OF FACE HEAD AND NECK
943.31 - 943.39	FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOREARM - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF UPPER LIMB EXCEPT WRIST AND HAND
944.34 - 944.38	FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF TWO OR MORE DIGITS OF HAND INCLUDING THUMB - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF WRIST(S) AND HAND(S)
945.32 - 945.39	FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF FOOT - FULL-THICKNESS SKIN LOSS DUE TO BURN (THIRD DEGREE NOS) OF MULTIPLE SITES OF LOWER LIMB(S)
946.0 - 946.5	BURNS OF MULTIPLE SPECIFIED SITES UNSPECIFIED DEGREE - DEEP NECROSIS OF UNDERLYING TISSUES DUE TO BURN (DEEP THIRD DEGREE) OF MULTIPLE SPECIFIED SITES WITH LOSS OF A BODY PART
951.4	INJURY TO FACIAL NERVE
952.00 - 952.9	C1-C4 LEVEL SPINAL CORD INJURY UNSPECIFIED - UNSPECIFIED SITE OF SPINAL CORD INJURY WITHOUT SPINAL BONE INJURY
953.0 - 953.9	INJURY TO CERVICAL NERVE ROOT - INJURY TO UNSPECIFIED SITE OF NERVE ROOTS AND SPINAL PLEXUS
955.0 - 955.9	INJURY TO AXILLARY NERVE - INJURY TO UNSPECIFIED NERVE OF SHOULDER GIRDLE AND UPPER LIMB
956.0 - 956.9	INJURY TO SCIATIC NERVE - INJURY TO UNSPECIFIED NERVE OF PELVIC GIRDLE AND LOWER LIMB
997.01	CENTRAL NERVOUS SYSTEM COMPLICATION
997.61	NEUROMA OF AMPUTATION STUMP
V43.60 - V43.7	UNSPECIFIED JOINT REPLACEMENT - LIMB REPLACED BY OTHER MEANS
V45.4	POSTSURGICAL ARTHRODESIS STATUS
V49.0 - V49.77	DEFICIENCIES OF LIMBS - HIP AMPUTATION STATUS
V52.0	FITTING AND ADJUSTMENT OF ARTIFICIAL ARM (COMPLETE) (PARTIAL)
V52.1	FITTING AND ADJUSTMENT OF ARTIFICIAL LEG (COMPLETE) (PARTIAL)
V52.8	FITTING AND ADJUSTMENT OF OTHER SPECIFIED PROSTHETIC DEVICE
V53.7	FITTING AND ADJUSTMENT OF ORTHOPEDIC DEVICES
V53.8	FITTING AND ADJUSTMENT OF WHEELCHAIR
V53.90 - V53.99	FITTING AND ADJUSTMENT OF UNSPECIFIED DEVICE - FITTING AND ADJUSTMENT OF OTHER DEVICE
V54.09	OTHER AFTERCARE INVOLVING INTERNAL FIXATION DEVICE
V54.10 - V54.89	AFTERCARE FOR HEALING TRAUMATIC FRACTURE OF ARM UNSPECIFIED - OTHER ORTHOPEDIC AFTERCARE
V57.81	CARE INVOLVING ORTHOTIC TRAINING

The following is are the only ICD-9 codes that will allow coverage for CPT 97033 - Iontophoresis application of a modality
Note: ICD-9 codes must be coded to the highest level of specificity.

705.21	PRIMARY FOCAL HYPERHIDROSIS
726.0 - 726.91	ADHESIVE CAPSULITIS OF SHOULDER - EXOSTOSIS OF UNSPECIFIED SITE
727.00	SYNOVITIS AND TENOSYNOVITIS UNSPECIFIED
727.01	SYNOVITIS AND TENOSYNOVITIS IN DISEASES CLASSIFIED ELSEWHERE
905.6	LATE EFFECT OF DISLOCATION
905.7	LATE EFFECT OF SPRAIN AND STRAIN WITHOUT TENDON INJURY
905.8	LATE EFFECT OF TENDON INJURY

Diagnoses that Support Medical Necessity
All diagnoses listed in ICD-9-CM Codes that Support Medical Necessity above.
ICD-9 Codes that DO NOT Support Medical Necessity

All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medical Necessity above.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity
All ICD-9-CM codes not listed in this policy under ICD-9-CM Codes that Support Medical Necessity above

General Information

Documentations Requirements

The patient's medical record must contain documentation that fully supports the medical necessity for services included within this LCD. This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, the time of any assessment is included and billed within the appropriate treatment intervention CPT code.

Under Medicare, time spent in documentation of services (medical record production) is part of the coverage of the respective CPT code; there is no separate coverage for time spent on documentation. Medicare requires a legible identifier of the person(s) who provided the service. The method used shall be a hand written or an electronic signature to sign an order or other medical documentation for medical review purposes. Electronic or hand written signatures that have been communicated through facsimile are also acceptable. Effective April 28, 2008, stamp signatures were no longer acceptable.

The document guidelines in CMS Pub 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 220 and 230 identify the minimal expectations of documentation by qualified practitioners or suppliers when submitting claims for payment of therapy services to the Medicare program. Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:

Describe the patient's impairments and functional limitations requiring skilled intervention, the prior functional level to assist in establishing the patient's potential and the frequency and duration of therapy.
- Clearly document both Timed Code Treatment Minutes and Total Treatment Time in order to justify the units billed;
- Identify each specific skilled intervention/modality provided to justify coding.

Initial Evaluation
The initial evaluation, which must be performed by a clinician, should document the medical necessity of a course of therapy through objective findings and subjective patient self-reporting. Documentation of the initial evaluation should list the conditions being treated and any complexities that make treatment more lengthy or difficult. Where it is not obvious, describe the impact of the conditions and complexities so that it is clear to the medical reviewer that the services planned are appropriate for the individual.

The initial evaluation establishes the baseline data necessary for assessing expected rehabilitation potential, setting realistic goals and measuring progress. Initial evaluations need to provide objective, measurable documentation of the patient's impairments and how any noted deficits affect ADLs/IADLs and result in functional limitations. Functional limitations refer to the inability to perform actions, tasks and activities that constitute the "usual activities" for the patient. Functional limitations must be meaningful to the patient and caregiver, and must have potential for improvement. In addition, the remediation of such limitations must be recognized as medically necessary.

To support medical necessity, the evaluation should include the following items.
- Presenting condition or complaint
o Patients should exhibit a significant change from their "usual" physical or functional ability to warrant an evaluation.
o Provide an objective description of the changes in function that now necessitate skilled therapy. Simply stating "decline in function" does not adequately justify the initiation of therapy services.
- Diagnosis and description of specific problem(s) to be evaluated
o Include area of the body, and conditions and complexities that could impact treatment
- Subjective complaints and date of onset
- Relevant medical history
o Applicable medical history, medications, comorbidities (factors that make therapy more complicated or require extra precautions)
- Prior diagnostic imaging/testing results
- Prior therapy history for the same diagnosis, illness or injury
o If recent therapy was provided, documentation must clearly establish that additional therapy is reasonable and necessary
- Social support/environment
o Document if the patient live alone, with a caregiver, in a group home, in a residential care facility, in a skilled nursing facility (SNF), etc?
- What level of support is available, and what level of independence is required for the patient to be safe in the home environment?
o Document any home obstacles that the patient must overcome (e.g., stairs without handrails) and usual responsibilities in the home environment?
- Prior level of function
o Key piece of information used for establishing potential, prognosis and realistic functional goals
o Functional status just prior to the onset of the condition requiring therapy
o Record in objective, measurable and functional terms
- Functional testing
o Objectively measure and/or describe the patient's current level of functioning.
Examples, based on the patient's need, may include:
- mobility status (transfers, bed mobility, gait, etc);
- self-care dependence (toileting, dressing, grooming, etc);
- meaningful ADLs/IADLs;
- pain, and how it limits function; and
- functional balance.
o Objective impairment testing
- Testing done to determine the source or cause of the functional limitation(s), such as ROM, manual muscle testing, coordination, tone assessment, balance etc.
- Use concise, objective measurements. Avoid minimal/moderate/severe types of descriptions when more specific definitions or measurements are available. For example, when measuring shoulder flexion AROM, document degrees of motion, rather than documenting, "Shoulder flexion: minimal loss of motion."
o Assessment
- Summary of the therapist's analysis of the condition being evaluated based on the examination of the patient. Clinical reasoning for treatment should be evident when further therapy is recommended.
- Prognosis for return to prior functional status, or the maximum expected condition
- Plan of care
- Signature and credentials of the therapist or physician/NPP completing the initial evaluation and plan of care.

Re-evaluations
See CPT 97002 and 97004 for coverage guidelines for therapy re-evaluations.

Re-evaluation documentation must include clear justification for the need for further tests and measurements after the initial evaluation, such as new clinical findings, a significant, unanticipated change in the patient's condition, or failure to respond to the interventions in the plan of care. It is expected that clinicians continually assess the patient's progress as part of the ongoing therapy services. This assessment is not considered a formal re-evaluation; the time of any assessment is included and billed within the appropriate treatment intervention CPT code.

Re-evaluations must be performed by clinicians and contain all applicable components of the initial evaluation. Resolved problems do not need to be re-evaluated; new or ongoing problems may need to be re-evaluated, especially if there is an anticipated change to the long term goals.

Progress Reports
Progress reports shall be written by a clinician at least once every 10 treatment days or at least once every 30 calendar days, whichever is less. Writing progress reports more frequently than the minimum is encouraged to support the medical necessity of treatment. A progress report is not a separately billable service. (CMS Publication 100-02, Medicare Benefit Policy Manual, chapter 15, sections 220-230),

Medicare defines the minimum REQUIRED elements of a progress report. It is essential that clinicians include all required elements in their documentation (either in a progress report or treatment note).

No specific format is required to demonstrate patient progress as long as all information noted in the bullets above are included at least once in the medical record for each progress report period (10 treatment days or 30 calendar days, whichever is less). Progress report information may be included in the treatment notes, progress reports and/or formal re-evaluations (when re-evaluation guidelines are met).

During each progress report period, the clinician must personally furnish in its entirety at least one billable service on at least one day of treatment. Verification of the clinician's treatment shall be documented by the clinician's signature on the treatment note and/or progress report.

Treatment Notes
Medical record documentation is required for every treatment day, and every therapy service to justify the use of codes and units on the claim.

The treatment note must include the following required information:
- date of treatment;
- identification of each specific treatment, intervention or activity provided in language that can be compared with the CPT codes to verify correct coding;
- record of the total time spent in services represented by timed codes under timed code treatment minutes;
- record of the total treatment time in minutes, which is a sum of the timed and untimed services;
- signature and credentials of each individual(s) that provided skilled interventions.
In addition, the treatment note may include any information that is relevant in supporting the medical necessity and skilled nature of the treatment, such as:
- patient comments regarding pain, function, completion of self management/home exercise program (HEP), etc;
- significant improvement or adverse reaction to treatment;
- significant, unusual or unexpected changes in clinical status;
- parameters of modalities provided and/or specifics regarding exercises such as sets, repetitions, weight;
- description of the skilled components of the specific exercises, training, or activities;
- instructions given for HEP, restorative or self/caregiver managed program, including updates and revisions;
- communication/consultation with other qualified practitioners (e.g., supervising clinician, attending physician, nurse, another therapist);
- communication with patient, family, caregiver;
- equipment provided
- any additional relevant information to support that the patient continues to require skilled therapy and that the unique skills of a therapist were provided.

If grid or checklist forms are used for daily notes or exercise/activity logs, include the signature and credentials of the qualified professional/auxiliary personnel providing the service each day. Listing of exercise names (e.g., pulleys, UBE, TKE, SLR) does not alone imply that skilled treatment has been provided, especially if the exercises have been performed over multiple sessions. Be sure to occasionally document the skilled components of the exercises so they do not appear repetitive and therefore, unskilled. Documenting functional activities performed (e.g., "ambulated 35 feet with min assist", "upper body dressing with set up and supervision") also does not alone imply that skilled treatment was provided. The skilled components/techniques of the qualified professional/auxiliary personnel used to improve the functional activity should be occasionally documented to support medical necessity.

When documenting treatment time, consistently use the CMS language of total "Timed Code Treatment Minutes" and "Total Treatment Time". Do not use other language or abbreviations when referring to treatment minutes as it may be difficult for medical review to determine the type of minutes documented.

Do not record treatment time as "Time in / Time out" for the entire session as this does not accurately reflect the actual treatment time. Do not "round" all treatments to 15-minute increments, but rather record the actual treatment time. Also do not record as "units" of treatment, instead of minutes.

Only "intra-service care" of skilled therapy services should be reflected in the time documentation. Do not include unbillable time, such as time for:
- changing;
- waiting for treatment to begin;
- waiting for equipment;
- resting;
- toileting; or
- performing unskilled or independent exercises or activities.

Discharge Notes
A discharge note is required for each episode of treatment and must be written by the clinician. The discharge note is a progress report covering the time from the last progress report up to the date of discharge, and includes all required components of a progress report. The discharge note may be considered the last opportunity to justify the medical necessity of the entire treatment episode. Therefore, if a discharge summary has been completed, it may be prudent to submit it with any request of records for medical review, even if the claim under review is for a treatment period prior to the date of discharge.

In the case of an unanticipated discharge, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified auxiliary personnel. In the case of a discharge anticipated within 3 treatment days of the progress report, the clinician may provide objective goals which, when met, will authorize the assistant or qualified auxiliary personnel to discharge the patient. In that case, the clinician should verify that the services provided prior to discharge continued to require the skills of a therapist. There must be indication that the clinician has reviewed the treatment notes and agrees to the discharge.

Appendices

Utilization Guidelines

Utilization parameters (i.e. number expected of units/visits) have been removed from this LCD. However providers must be aware that any service reported to Medicare may be denied if done so in association with medical review (either pre or post payment) of the patients' record. Likewise, providers must understand that though Medicare allows payment of these services, the patient's medical record must clearly demonstrate that medical necessity of the services performed and billed to Medicare.

Rarely, except during an evaluation, should therapy session length be greater than 30-60 minutes. If longer sessions are required, documentation must support as medically necessary the duration of the session and the amount of interventions performed

The following interventions should be reported no more than one unit per code per day per discipline; additional units will be denied: CPT codes:
97001, 97002, 97003, 97004, 97012, 97016, 97018, 97022, 97024, 97028, 97150, 97597, 97598, 97605, 97606, G0281, G0283, G0329 (NOTE: for CPT codes 97597, 97598, 97605, 97606, G0281 and G0329
See LCD L28572 - GSURG-051).

The following timed interventions should be reported no more than 2 (two) units per code per day per discipline; additional units will be denied: CPT codes 97033, 97034, 97035, 97036

The following interventions should be reported no more than 4 (four) units per code per day per discipline; additional units will be denied: CPT codes:
97032, 97110, 97112, 97113, 97116, 97124, 97530, 97532, 97533, 97535, 97537, 97542, 97760, 97761, 97762

Sources of Information and Basis for Decision

APTA website (www.apta.org)
Baeten, Moran, Phillips Documenting Physical Therapy;
Burke T.J. (2006).The Effect of Monochromatic Infrared Energy on Sensation in Subjects with Diabetic Peripheral Neuropathy: A Double-Blind, Placebo-Controlled Study.Diabetes Care 29:1186 A response to Clifft et al. Retrieved on March 15, 2007 from http://care.diabetesjournals.org/cgi/content/full/29/51186
Cohen; Kimball; Improvements in path integration after vestibular rehabilitation; Journal Vestibular Research; 2002; 12(1): 47-51
Frontera: Essentials of Physical Medicine and Rehabilitation, 1st ed., 2002 Hanley and Belfus
Goetz: Textbook of Clinical Neurology, 2nd ed., Copyright© 2003 Elsevier
Goldman: Cecil Textbook of Medicine, 22nd ed., 2004 W.B. Saunders Company
Guide to Physical Therapist Practice, APTA, 2nd Ed., 2003
Guidelines for Cognitive Rehabilitation, Neuro-Rehabilitation, Aug 1992: pp 62-67.
Harris: Kelley's textbook of Rheumatology, 7th ed., Copyright© 2005 Elsevier
Herdman, S. et al.; Strategies for Balance Rehabilitation; Annals of the New York Academy of Sciences; 2001 Oct; 942:394-412
Leonard D.R., Farooqi M.H., Myers S., (2004). Restoraion of Sensation, Reduced Pain, and Improved Balance in Subjects with Diabtic Peripheral Neuropathy. Diabetes Care 27:168-172 Retrieved on March 15, 2007 from http://care.diabetesjournals.org/cgi/content/full/27/1/168?maxtoshow=HITS=10hits
Noble: Textbook of Primary Care Medicine, 3rd ed., Copyright© 2001 Mosby, Inc.
Physical Therapist's Clinical Companion; Springhouse Corporation
Reimbursement and Coding for Rehabilitation Services in the Outpatient Setting, APTA, February 2006
Vestibular rehabilitation: Useful but not universally so; Otololaryngology Head and Neck Surgery 2003 Feb; 128(2): 240-50

Advisory Committee Meeting Notes

Wisconsin 09/26/2008
Illinois 09/17/2008
Michigan 09/24/2008
Minnesota 09/11/2008
Iowa 10/16/2008
Kansas 10/16/2008
Missouri 10/17/2008
Nebraska 10/16/2008

This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies. This LCD replaces all previous therapy policies including PHYSMED-001, PHYSMED-509, PHYSMED-009, and

Start Date of Comment Period

10/18/2008

End Date of Comment Period

12/03/2008

Start Date of Notice Period

12/01/2009

Revision History Number

Revision History Explanation

08/01/2009, one, This LCD replaces Legacy B: PHYSMED-009 Physical Medicine and Rehabilitation; NCP PHYS-001 Outpatient Physical Therapy, MAC B: L26688 PHYSMED-509 Physical Medicine and Rehabilitation

09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.

10/01/2010, one, 2011 ICD-9 update, added 488.01, 488.02, 488.09, 488.11, 488.12, 488.19, 724.03, 787.60-787.63

12/01/2010, two, changed CPT code 97026 information, corrected typo CPT code 97520 changed to 97761;

11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
97024 descriptor was changed in Group 1
97597 descriptor was changed in Group 1
97598 descriptor was changed in Group 1
97605 descriptor was changed in Group 1
97606 descriptor was changed in Group 1

08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.

10/01/2011, 2012 ICD-9 updates, Added ICD-9 codes 358.00 - 358.9

11/01/2011, updated ICD-9, based on 2012 update to exclude the codes that are no longer in the range;
ICD-9 range 487.0-491.9 deleted and replaced with ICD-9 ranges 487.0-488.19 and 490-491.9; ICD-9 range 508.0-508.9 deleted and replaced with ICD-9 ranges 508.0-508.1 and 508.8-508.9; ICD-9 range
512.0-512.8 deleted and replaced with ICD-9 code 512.0 - 512.1; ICD-9 range 516.0-516.9 deleted and replaced with ICD-9 codes 516.0, 516.1, 516.2, 516.8, 516.9, 517.1-517.8, 518.0-518.3, 518.6-518.89 Effective 10/01/2011.

Reason for Change

License for Use of "Physicians' Current Procedural Terminology", Fourth Edition ("CPT")

LICENSE FOR USE OF DENTAL PROCEDURE CODES, FOURTH EDITION ("CDT")

US Government Rights

Outpatient Rehabilitation Therapy Services billed to Medicare Part B (L28531)

Contractor Information

LCD Information

Coding Information

General Information