MP-22 Physical Therapy and Occupational Therapy 2018 Form

Medical Policy Physical Therapy and Occupational Therapy

Physical Therapy and Occupational Therapy Review/Revision Date: 11/27/2020 Page 1 of 8

Current Effective Date: 8/22/2018 Original Effective Date: 8/22/2018 Next Review/Revision Date: 8/22/2019, 11/27/2020 Plans: QUEST Integration (Medicaid), AlohaCare Advantage Plus Special Needs Plan (SNP Medicare)

I. Definition Physical therapy (PT) is the treatment of disease or injury using therapeutic exercise and other interventions that focus on range of motion, improving posture, locomotion, strength, endurance, balance, coordination, joint mobility, flexibility, and on alleviating pain. Physical therapy also integrates all of the above so a patient may regain functional activities of daily living. Treatment may include active and passive modalities using a variety of means and techniques based upon biomechanical and neurophysiological principles.

Occupational therapy (OT) evaluates and treats neuromusculoskeletal and psychological symptoms or disorders through the use of specific tasks or goal-directed activities designed to improve the functional performance of an individual. Occupational therapy involves cognitive, perceptual, safety, and judgment evaluations and training related to activities of daily living. Occupational therapy also includes the design, fabrication, and use of orthoses, guidance in the selection and use of adaptive equipment, and sensory- integrative and perceptual-motor activities.

II. Criteria
Physical therapy and occupational therapy are covered if all of the following criteria have been met: A. The therapy must be ordered by a physician or other licensed health care practitioner who has established the member’s diagnosis and are qualified to prescribe physical therapy or occupational therapy within the scope of work. B. The therapy must be provided by a physical therapist or physical therapist assistant who must practice within the scope of licensure under the supervision of the physical therapist.
C. The therapies are ordered to improve, develop, or restore neurological and/or musculoskeletal functions lost or impaired due to disease, trauma, surgical procedures, congenital anomalies, or prior therapeutic intervention. D. The therapy is to achieve a specific diagnosis-related goal for a member who has a reasonable expectation of achieving significant improvement in a reasonable and predictable period of time within a month. Significant is defined as a measurable and meaningful increase (as documented in the patient’s record) in the patient’s level of physical and functional abilities that can be attained with short-term therapy, usually within a three month period. Measures of progress include:

1. Physical therapy

Medical Policy Physical Therapy and Occupational Therapy

Physical Therapy and Occupational Therapy Review/Revision Date: 11/27/2020 Page 2 of 8

• Active range of motion • Strength
• Motor exam • Functional abilities

2. Occupational therapy • Useful and purposeful activities (neuromusculoskeletal) • Guidance in the selection and use or orthoses • Functional abilities (skill and deficits) E. The therapy must include a home exercise/education program to be initiated at the first physical therapy visit. The physical therapist or the physical therapist assistant must document the member’s participation in and compliance with the home exercise/education program.
   F. The frequency of visits shall be appropriate according to the member’s physical condition and stage of healing.
   G. Up to one-hour per visit is covered.

   III. Guidelines
   A. Prior Authorization (PA) is not required for the initial evaluation and re-evaluation of PT and OT within a six month period in a benefit year.
   B. PA is not required for one PT or OT treatment on the same day with the initial evaluation and re- evaluation visits.
   C. PA is required for the following:

3. Additional evaluations exceed the limit under III.A.
4. Additional PT or OT treatments after the initial evaluation and re-evaluation.
5. Evaluation and treatment for speech therapy. D. Documentation submitted along with PA must include an individualized, written treatment plan that include the following information:
6. Diagnosis, symptoms and findings of the evaluation which clearly documents the medical necessity of the treatment
7. The date of onset or exacerbation of the disorder or diagnosi s
8. Long-term and short term-goals that are specific, quantitative, and objective. Goals should include a transition from one-to-one supervision to a member, family member or caregiver upon discharge to a home maintenance program
9. Therapy evaluation
10. Measurable objectives intended to facilitate meaningful functional improvement
11. A reasonable estimate of when the goals will be reached
12. Frequency and duration of treatment

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8. The specific procedures and/or modalities to be used in treatment including those for use in a home maintenance program

   IV. Limitations A. PT or OT is not covered when any other therapy is provided concurrently with the same interventions and treatment for the same purpose.
   B. PT and OT are not covered for the following purposes:

9. Leisure activities including hobbies, sports or recreation of all types even if suggested as part of a PT treatment plan. This includes continued treatment for sports related injuries in an effort to improve above and beyond normal ability to perform activities of daily living; it is not intended to return the individual to their previous (or improved) level of sports competition or capability
10. Ongoing treatment solely to improve endurance and distance
11. General exercise programs to promote overall fitness
12. Programs to provide diversion or general motivation
13. Long term therapy
14. Developmental delay defined as any significant lag in a child's physical, cognitive, behavioral, emotional, or social development, in comparison with norms
15. Conditions considered as routine educational, training, conditioning, or fitness C. PT and OT is considered not medically necessary if:
16. Member’s conditions are not improving
17. The function could reasonably be expected to improve as the member gradually resumes normal activities D. The following modalities are not reimbursed separately with the therapy since they are considered as components of comprehensive PT or OT treatment plan:
18. Functional activities and activities of daily living
19. Infrared and ultraviolet
20. Massage therapy and myofascial release
21. Microwave and infrared
22. Orthotics training and prosthetic training
23. Whirlpool and Hubbard tank E. Electrical stimulation (E-stim/NMES) for swallowing/feeding disorders is not covered as it is not known to improve health outcomes.

Medical Policy Physical Therapy and Occupational Therapy

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V. Coding Information The following medical codes are relevant codes for diagnosis and procedures for physical therapy and occupational therapy and should be used for informational purposes only. All the medical codes listed in this policy do not constitute or imply benefit coverage or guarantee provider reimbursement.

CPT Description PA Policy 64550 Application of surface (transcutaneous) neurostimulator (eg, TENS unit) Yes 90901 Biofeedback training by any modality Yes 90911 Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry Yes 92507 Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual Yes 92508 Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals Yes 92520 Laryngeal function studies (ie, aerodynamic testing and acoustic testing) Yes 92521 Evaluation of speech fluency (eg, stuttering, cluttering) Yes 92522 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); Yes 92523 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language) Yes 92524 Behavioral and qualitative analysis of voice and resonance Yes 92526 Treatment of swallowing dysfunction and/or oral function for feeding Yes 92597 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech Yes 92605 Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour Yes 92606 Therapeutic service(s) for the use of non-speech-generating device, including programming and modification Yes 92607 Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour Yes 92608 Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) Yes 92609 Therapeutic services for the use of speech-generating device, including programming and modification Yes

Medical Policy Physical Therapy and Occupational Therapy

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CPT Description PA Policy 92610 Evaluation of oral and pharyngeal swallowing function Yes 92611 Motion fluoroscopic evaluation of swallowing function by cine or video recording Yes 92612 Flexible endoscopic evaluation of swallowing by cine or video recording; Yes 92614 Flexible endoscopic evaluation, laryngeal sensory testing by cine or video recording; Yes 92616 Flexible endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording; Yes 92618 Evaluation for prescription of non-speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) Yes 95831 Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk Yes 95832 Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side Yes 95833 Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands Yes 95834 Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands Yes 95851 Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine) Yes 95852 Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side Yes 95992 Canalith repositioning procedure(s) (eg, Epley maneuver, Semont maneuver), per day Yes 96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston Diagnostic Aphasia Examination) with interpretation and report, per hour Yes 96111 Developmental testing, (includes assessment of motor, language, social, adaptive, and/or cognitive functioning by standardized developmental instruments) with interpretation and report Yes 96125 Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional's time, both face- to-face time administering tests to the patient and time interpreting these test results and preparing the report Yes 97010 Application of a modality to 1 or more areas; hot or cold packs Yes

Medical Policy Physical Therapy and Occupational Therapy

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CPT Description PA Policy 97012 Application of a modality to 1 or more areas; traction, mechanical Yes 97014 Application of a modality to 1 or more areas; electrical stimulation (unattended) Yes 97016 Application of a modality to 1 or more areas; vasopneumatic devices Yes 97018 Application of a modality to 1 or more areas; paraffin bath Yes 97022 Application of a modality to 1 or more areas; whirlpool Yes 97024 Application of a modality to 1 or more areas; diathermy (eg, microwave) Yes 97026 Application of a modality to 1 or more areas; infrared Yes 97028 Application of a modality to 1 or more areas; ultraviolet Yes 97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Yes 97033 Application of a modality to 1 or more areas; iontophoresis, each 15 minutes Yes 97034 Application of a modality to 1 or more areas; contrast baths, each 15 minutes Yes 97035 Application of a modality to 1 or more areas; ultrasound, each 15 minutes Yes 97036 Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes Yes 97039 Unlisted modality (specify type and time if constant attendance) Yes 97110 Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Yes 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 Yes 97113 Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Yes 97116 Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) Yes 97124 Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion) Yes 97139 Unlisted therapeutic procedure (specify) Yes 97140 Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Yes 97150 Therapeutic procedure(s), group (2 or more individuals) Yes 97161-97164 Physical therapy evaluation and re-evaluation
No PA
for the initial evaluation

Medical Policy Physical Therapy and Occupational Therapy

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CPT Description PA Policy and reevaluation within a 6- month period 97165-97168 Occupational therapy evaluation and re-evaluation No PA
for the initial evaluation and reevaluation within a 6 month period 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes Yes 97532 Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes Yes 97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes Yes 97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes Yes 97537 Community/work reintegration training (eg, shopping, transportation, money management, avocational activities and/or work environment/modification analysis, work task analysis, use of assistive technology device/adaptive equipment), direct one-on-one contact, each 15 minutes Yes 97542 Wheelchair management (eg, assessment, fitting, training), each 15 minutes Yes 97750 Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes Yes 97755 Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes Yes 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 Yes 97761 Prosthetic training, upper and/or lower extremity(s), each 15 minutes Yes 97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes Yes

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CPT Description PA Policy 97799 Unlisted physical medicine/rehabilitation service or procedure Yes

HCPCS
Description PA Policy G0283

Electrical stimulation, (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
Yes G0451 Development testing, with interpretation and report, per standardized instrument form Yes

References/Resources Document Name Effective Date Source/Link Outpatient Rehabilitation and CORF/OPT Services
12/21/2017 Medicare Claims Processing Manual Chapter 5
https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c05.pdf
220-Coverage of Outpatient Rehabilitation Therapy Services
7/11/2017 Medicare Benefit Policy Manual Chapter 15 https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/bp102c15.pdf

Review/Revision History 11/27/2020 - Retired