For claims submitted by
a physician or NPP:
• Services performed by non-employees or those not under a
physician’s or NPP’s direct supervision are not covered.
• Services not relating to a written treatment plan are not
medically necessary.
• Services that do not require the professional skills of a
physician or NPP to perform or supervise are not medically necessary.
For claims submitted by a Physical or Occupational Therapist (PT or OT) or
Speech-Language Pathologist (SLP) in independent practice:
• 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.
• Claims submitted by anyone other than a therapist enrolled
as a Medicare provider are not covered.
• Services not performed by or under the direct supervision
of the therapist are not covered.
• Services performed by people who are not employees of the
therapist are not covered.
• Services not furnished in the therapist’s office or in the
patient’s home are not covered.
• Physical therapy services that do not require the professional
skills of a qualified PT to perform or supervise are not medically necessary.
• Occupational therapy services that do not require the
professional skills of a qualified OT to perform or supervise are not medically
necessary.
• Speech-language pathology services that do not require the
professional skills of a qualified SLP to perform or supervise are not
medically necessary.
Maintenance Therapy
Maintenance therapy after therapeutic goals and/or rehabilitative potentials
are reached is medically reasonable and necessary but is not covered. However,
a qualified professional may develop a maintenance program for the patient to
pursue outside of a therapy program and plan of care, generally administered
and supervised by family or caregivers. Periodic evaluations of the patient’s
condition and response to treatment may be covered when medically necessary if
the judgment and skills of a qualified professional are required. Examples
include:
• Design of a maintenance regimen required to delay or
minimize muscular and functional deterioration in patients suffering from a
chronic disease.
• Instructing the patient, family member(s) or caregiver(s)
in carrying out the maintenance program.
• Infrequent re-evaluations required to assess the patient’s
condition and adjust the program.
If a maintenance program is not established until after the therapy program has
been completed (and the skills of a therapist are not necessary), development
of a maintenance program is not considered reasonable and necessary for the
patient’s condition.
Note: Bill these services (e.g., codes 99212, 99213, 99214, 99215, 97002,
97004) with the appropriate evaluation/re-evaluation. It is expected these
services will be infrequently required.
• Modality codes 97012 (mechanical traction) and 97016,
97018, 97022, 97024, 97026, 97028 (vasopneumatic device, paraffin bath therapy,
whirlpool therapy, diathermy, and ultraviolet therapy) require supervision by
the qualified professional; codes 97032, 97033, 97034, 97035, 97036, 97039
(electrical stimulation, contrast bath therapy, ultrasound therapy,
hydrotherapy, and physical therapy treatment unlisted) require direct
(one-on-one) contact with the patient by the qualified professional.
• Therapeutic exercise and activities are essential for
rehabilitation. The use of modalities as stand-alone treatment is not indicated
as a sole approach to rehabilitation. Therefore, an overall course of
rehabilitative treatment is expected to consist predominantly of therapeutic
procedures (such as codes 97110 (therapeutic exercises), 97112 (neuromuscular
re-education), 97116 (gait training therapy) and/or 97530 (therapeutic
activities)), with adjunctive use of modalities. Although passive modalities
may play a larger role in the early stages of rehabilitation and in treating
exacerbations it is expected that modalities will comprise a small portion of
the total therapy service time involved during the course of rehabilitative
therapy. Further, it is expected that the record will demonstrate both the
patient’s clinical progress and concomitant appropriate increasingly active
therapeutic treatment.
• When modality codes 97012 (mechanical traction) and 97018
(paraffin bath therapy) are used alone (absent therapeutic procedures and not
as a precursor to active treatment) and solely to promote healing, relieve
muscle spasm, reduce inflammation and edema, or as analgesia, a limited number
of visits (e.g., 1–2) visits may be medically necessary to determine the
effectiveness of treatment and for patient education. It is usually not
medically reasonable and necessary to continue modality-only treatment by the
qualified professional.
• Generally, adjunctive use of services billed with modality
codes 97012 (mechanical traction) and 97018 (paraffin bath therapy) is
coverable only if they enhance the therapeutic procedures. Documentation
supporting the medical necessity and clinical justification for the services’
continued use must be made available to Medicare upon request.
• Generally, only one heating modality per day of therapy is
reasonable and necessary. Medicare would not expect to see multiple heating
modalities billed routinely on the same day. Exceptions could include
musculoskeletal pathology/injuries in which both superficial and deep
structures are impaired. Documentation containing clinical justification
supporting the medical necessity for multiple heating modalities such as codes
97018, 97024, and 97035 on the same day is essential.
• Generally, only one hydrotherapy modality is coverable per
day when the sole purpose is to relieve muscle spasm, inflammation or edema.
Documentation must be available supporting the use of multiple modalities as
contributing to the patient’s progress and restoration of function. Because
some of the modalities are considered components of other modalities and
procedures they are not separately reimbursed. Please refer to the Correct
Coding Initiative.
• Medicare does not provide payment for the therapeutic
modality described as iontophoresis (procedure code 97033).
• Medicare does not provide payment for the therapeutic
modality described as phonophoresis.
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