Outpatient Physical and Occupational Therapy Form

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Outpatient Physical and Occupational Therapy - Medical Policy
Updated Revision Effective: March 1, 2025 Policy Number:

UM376POL

Approval Date: 12/19/2024

Line(s) of Business: Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Physical therapy (PT) is defined as skilled therapy services, including diagnostic evaluation and therapeutic intervention, which are designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functional capabilities that are impaired or have been reduced as a result of specific disease, injury, or congenital disorder. Skilled physical therapy incorporates services such as individual rehabilitative exercises, skilled manual techniques, therapeutic modalities, assistive and adaptive devices, and physical agents and mechanical modalities. Physical therapy emphasizes skilled rehabilitative or habilitation-focused treatment of dysfunctions involving neuromuscular, musculoskeletal, cardiovascular, pulmonary, and/or integumentary systems to optimize functional levels.

Occupational therapy (OT) is defined as skilled therapy services, including diagnostic evaluation and therapeutic intervention, which are designed to improve, develop, correct, rehabilitate, or prevent the worsening of functions that affect the activities of daily living (ADLs), including self-care (i.e., bathing, dressing, feeding, grooming, toileting) and instrumental activities of daily living (IADLs) that are impaired or have been reduced as a result of specific disease, injury, or congenital disorder. Skilled occupational therapy programs are designed to improve quality of life by recovering competence and preventing further injury or disability, and to improve the individual’s ability to perform tasks required for independent functioning.

 Line of Business

Commercial:

• Refer to criteria under the Policy section in this medical policy.

Medicaid – BeHealthy:

• HNE follows MassHealth Guidelines for Medical Necessity Determination for Physical Therapy or Occupational Therapy. https://www.mass.gov/lists/masshealth-guidelines-for-medical-necessity- determination

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Medicare:

• Health New England follows Local Coverage Determination (LCD) Outpatient Physical and Occupational Therapy Services (L33631). MCD Search (cms.gov)

Policy

I. Criteria for Approval of Outpatient Physical and Occupational Therapy Services for Commercial line of business:

A. Physical and Occupational Therapy are considered MEDICALLY NECESSARY when individual presents with signs and symptoms of physical deterioration or impairment in one or more of the following areas:

1. Sensory/motor ability – problems with sensory integration, attention and cognition, circulation, cranial and peripheral nerve integrity, ergonomics and body mechanics, gait, locomotion and balance, integumentary integrity, joint integrity and mobility, motor function, muscle performance, neuromotor development, posture, range of motion, reflex or sensory integrity.

2. Functional status – inability to perform basic activities of daily living (ADLs) or instrumental
   activities of daily living (IADLs) that involve personal self-care (e.g., feeding, dressing, bathing, or continence), functional mobility for home management (e.g., making a bed), work, school, or community activities.

3. Cognitive ability – problems with orientation, concentration (attention loss),
   comprehension, learning, organization of thought, problem solving, or memory.

4. Respiratory ability – impairments in aerobic capacity, aerobic endurance, ventilation, or respiration change;

   AND

   C. A comprehensive evaluation has been conducted by a licensed physician or clinician to determine the individual’s current medical status, disability, level of functioning, health and psychosocial status, and the need for treatment; AND

   D. A written treatment plan that includes ALL of the following elements has been developed:

5. The diagnosis with date of onset or exacerbation of the condition.
6. The anticipated functional treatment goals and potential for achievement.
7. The short-term and long-term functional treatment objectives that are specific and measurable
8. The treatment techniques and interventions to be used, including amount, frequency, and duration required to achieve goals.
9. Plan of education of the individual and primary caregiver to promote awareness and understanding of diagnosis, prognosis, and treatment; AND

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E. Therapy services are reasonable, necessary and of a level of complexity and sophistication for the members condition sophistication that can only be safely and effectively performed by a licensed therapist or under their supervision; AND

F. Therapy services are expected to significantly improve the individual’s condition within a reasonable and predictable period of time, or prevent the worsening of functions that affect the ADLs that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries, AND

G. The amount, frequency, and duration of services are reasonable by professionally recognized standards of practice for therapy; AND

a. After the initial evaluation of the extent of the disorder, illness, or injury, the treating qualified professional determines the potential for rehabilitation is significant and an appropriate maintenance program is established prior to discharge by a skilled therapist, OR

b. If the services required to maintain function involve the use of complex and sophisticated therapy procedures as devised by a skilled therapist, when the patient's safety is at risk, those reasonable and necessary services shall be covered, even if the skills of a therapist are not ordinarily needed to carry out the activities performed as part of the maintenance program, OR

c. For progressive degenerative disease, services are intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function.

II. Following indications for Physical and Occupational Therapy are not considered medically necessary for Commercial line of business:

A. The services involve non-diagnostic, non-therapeutic, routine, or repetitive procedures to maintain general welfare and do not require the skilled assistance of a licensed therapist.

B. The treatment constitutes non-therapeutic services, such as general exercise programs to promote overall fitness and endurance, for diversion or for general motivation, or for return to competitive sports.

C. The therapy replicates services that are provided concurrently by any other type of therapy, particularly occupational therapy and speech and language therapy (which should provide different treatment goals, plans, and therapeutic modalities).

D. There is no clinical documentation or treatment plan to support the need for therapy services or continuing therapy.

E. Services are considered investigational or experimental in nature including, but not limited to facilitated communication, auditory integration therapy (AIT), holding therapy, Higashi (Daily Life Therapy).

F. Services that can be safely and effectively furnished by nonskilled personnel or by physical therapy assistants or occupational therapy assistants without the supervision of therapists.

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G. If an individual's expected rehabilitation potential would be insignificant in relation to the extent and duration of physical therapy services required to achieve such potential, such therapy would not be covered because it would not considered rehabilitative nor medically necessary.

H. Vocational rehabilitation or vocational evaluations focused on job adaptability, job placement, or therapy to restore function for a specific occupation.

I. Therapy to effect improvement or restoration of function where a member suffers a transient and easily reversible loss or reduction in function which could reasonably be expected to improve spontaneously as the member gradually resumes normal activities.

J. If an individual has a limited ability to comprehend instructions, follow directions, or remember skills that are necessary to achieve an increase in function that is so severe as to make functional improvement very unlikely.

K. Continuation of treatment solely for the purpose of staff training and education, or development of a formal maintenance program after rehabilitative therapy has been completed (It is expected that a maintenance program is developed during the course of rehabilitative treatment).

L. Any service(s), program(s), supply, or procedure performed in a non-conventional setting, which includes, but is not limited to, spas/resorts; educational, vocational, or recreational settings; Outward Bound or wilderness, camp or ranch programs. This is the case even if the services are performed by a licensed provider including, but not limited to, mental health professionals, nutritionists, nurses or physicians.

M. Hippotherapy.

N. Physical therapy services provided by an athletic trainer (Personal training).

O. Life coaching.

N. Group therapy.

O. Palliative care.

P. Aquatic therapy.

IV. Criteria for Approval of Outpatient Physical and Occupational Therapy Services for Medicare:

• Health New England follows Local Coverage Determination (LCD) Outpatient Physical and Occupational Therapy Services (L33631).

LCD - Outpatient Physical and Occupational Therapy Services (L33631) (cms.gov)

• HNE does not request prior authorization (PA) for initial 25 physical therapy visits and/or 25 occupational therapy visits for Medicare members. For additional physical and occupational therapy visits, therapist are required to get PA within the same 12-month period.

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V. Criteria for Approval of Outpatient Physical and Occupational Therapy Services for Medicaid:

• HNE follows MassHealth Guidelines for Medical Necessity Determination for Physical Therapy and Occupational Therapy.

https://www.mass.gov/doc/physical-therapy/download

https://www.mass.gov/doc/occupational-therapy-0/download

• HNE does not request prior authorization (PA) for initial 25 physical therapy visits and/or 25 occupational therapy visits for Medicaid members. For additional physical and occupational therapy visits, therapist are required to get PA within the same 12-month period.

VI. PT and OT services for children with developmental delays or disabilities that fall under MGL 71B (referred to as Chapter 766) are not covered. Members must seek benefits available under MA state law and seek a Chapter 766 evaluation.

VII. PT and OT services for individuals from birth to age of 3 years must be obtained through an in-plan early intervention (EI) provider.

VIII. PT and OT services rendered in a Skilled Nursing Facility are only approved for 30 days at a time for all lines of business.

Policy Guidelines and Definitions

Policy Guidelines:

Commercial line of business

A. For rehabilitation services in a skilled nursing facility (SNF): • An authorization is required for any services in an SNF.
• The evaluation and treatment plan must be submitted along with the prior authorization request.
• This type of therapy is under their outpatient benefit when the room and boarding are not covered at SNF.
• Member must have documented progress with rehabilitation in order to continue with therapy.

B. For fully-funded and self-funded commercial plans, benefit limits vary and should be verified with Member Services.

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Required Documentation

A. For initial request:

1. A prescription from Provider within the last 30 days, including the diagnosis and description of the specific problem to be treated, the body part evaluated, all conditions and complexities that may impact the treatment such as premorbid function, date of onset, and current function.
2. For a member that is in a skilled nursing facility, copy of MD orders and initial therapy evaluation are needed.
3. Objective measurements related to current functional status for the condition being treated.

4. A prognosis for return to premorbid condition or maximum expected condition with expected time frame and a plan of care.

   B. For additional requests

5. Assessment of improvement, extent of progress (or lack thereof) toward each short term and long- term goals.
6. Plans for continuing treatment, include treatment plan revisions and expected progress.
7. Changes to long- or short-term goals, discharge or an updated plan of care.
8. An updated written prescription by treating physician within the last 30 days.
9. Treatment plan includes a home exercise program (HEP).

10. Amount, frequency and duration of rehabilitation services are reasonable according to professional standards of practice.

    Treatment of more than one condition or change in condition.

    A. If a member is under treatment for one condition and during this treatment develops another condition not directly related to the first condition, member may utilize a new benefit for this new condition. Criteria noted above applies to this secondary condition. Rehabilitation staff must provide separate documentation on each condition being treated.

    B. Member receiving rehabilitation services with development of a new condition related to the original condition being treated by therapy (such as requiring surgery) may be eligible for full rehabilitation benefit visits. Clinical records need to be reviewed to confirm new orders and treatment plan.

    Definitions:

    Aquatic Therapy: One to one therapy with therapeutic exercises performed in a pool.

    Hippotherapy (Equine Assisted Therapy=EAT): Refers to how OT, PT and SLP professionals use purposeful manipulation of equine movement to engage sensory, neuromotor, and cognitive systems to achieve functional outcomes.

    Habilitation Services: Health Services that help member acquire, improve or keep (partially or fully) skills related to activities of daily living (ADLs) along with communication skills. This can be done at different points in member’s life.

    Rehabilitation Services: Health services that help member keep, restore or improve functioning for ADLs and skills that are impaired or have been lost due to injury, illness or disability.

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Activities of Daily Living (ADLs): Activities of daily living are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.

Instrumental Activities of Daily Living (IADLs): Activities related to independent living. They include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone.

Coding Guidance

PA is required for all outpatient therapy services provided in a skilled nursing facility. Check the members benefit plan for details on limitations and authorization requirements for all other outpatient therapy.

Code
Description
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 97014 Application of a modality to 1 or more areas; electrical stimulation (unattended) 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 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) 97129 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes 97130 Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (eg, managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure) 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)

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Code
Description
97161 Physical therapy evaluation: low complexity, requiring these components: A history with no personal factors and/or comorbidities that impact the plan of care; An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with stable and/or uncomplicated characteristics; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 20 minutes are spent face-to- face with the patient and/or family. 97162 Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family. 97163 Physical therapy evaluation: high complexity, requiring these components: A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; A clinical presentation with unstable and unpredictable characteristics; and Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 45 minutes are spent face-to-face with the patient and/or family. 97164 Re-evaluation of physical therapy established plan of care, requiring these components: An examination including a review of history and use of standardized tests and measures is required; and Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome Typically, 20 minutes are spent face-to-face with the patient and/or family 97165 Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family. 97166 Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family. 97167 Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive

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Code
Description
assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family. 97168 Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to- face with the patient and/or family. 97530 Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes 97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes 97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minute 97542 Wheelchair management (eg, assessment, fitting, training), each 15 minutes 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes 97761 Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes 97763 Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes The Following codes are NOT covered 97550 Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face; initial 30 minutes 97551 Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face; each additional 15 minutes (List separately in addition to code for primary service) 97552 Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [iADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face to face with multiple sets of caregivers CPT® Copyright 2025 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

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Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 10/10 Initial policy date 12/2023 Minor criteria changes.
Added applicable codes Added non-coverage for CPT 97550-97552 effective 1/2024 1/2024 Added Line of Business section 12/2024 Annual Review.
Title changed to Outpatient Physical and Occupational Therapy.
Section II (Not Medically Necessary Services for Commercial Line of Busingess • Clarified criteria in line E • Added line L- Any service(s), program(s), supply, or procedure performed in a non- conventional setting, which includes, but is not limited to, spas/resorts; educational, vocational, or recreational settings; Outward Bound or wilderness, camp or ranch programs. This is the case even if the services are performed by a licensed provider including, but not limited to, mental health professionals, nutritionists, nurses or physicians. • Clarified criteria in line N. • Added line O- Life coaching. Added Section VIII- PT and OT services rendered in a Skilled Nursing Facility are only approved for 30 days at a time for all lines of business.
Required Documentation section updated • A.1. updated prescription for therapy was written within last 30 days. • B.1. clarified that both long and short term goals are addressed.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).

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Health New England expressly reserves the right to revise these conclusions as clinical information changes and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.