Therapeutic procedures are procedures that attempt to reduce impairment and improve function through the application of clinical skills and/or services.
• Use of these procedures requires that the practitioner have direct (one-on-one) patient contact.
• Codes 97110 (therapeutic exercises), 97112 (neuromuscular re-education), 97113 (aquatic therapy/exercises) and 97530 (therapeutic activities) describe several different types of therapeutic interventions. The expected goals documented in the treatment plan, 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 more than one of codes 97110 (therapeutic exercises), 97112 (neuromuscular re-education), 97113 (aquatic therapy/exercises) and 97530 (therapeutic activities) may be used in a treatment plan, documentation must support the use of each code as it relates to specific therapeutic goal(s).
• Documentation supporting the medical necessity for continued treatment must be made available to Medicare upon request.
Specific Guidelines for Therapeutic Procedures
The following clinical guidelines pertain to the specific listed therapeutic procedures.
Per Change Request 2083
In accordance with established conditions, all rehabilitation services to beneficiaries with a primary vision impairment diagnosis must be provided pursuant to a written treatment plan established by a Medicare physician and implemented by approved Medicare qualified professionals (PTs or OTs) or as “incident to” physician services. Some of the following rehabilitation programs/services for beneficiaries with vision impairment may include Medicare covered therapeutic services.
• Mobility.
• Activities of daily living.
• Other medically necessary services, including low-vision services.
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, and maintenance therapy – services required to maintain a level of functioning – is not covered. For example, a person with an ICD-9-CM diagnosis of 369.08 (profound impairment in both eyes, i.e., best corrected visual acuity is less than 20/400 or visual field is 10 degrees or less) would generally be eligible for, and may be provided, rehabilitation services under CPT/HCPCS code 97535 (self-care/home management training, i.e., activities of daily living, compensatory training, meal preparation, safety procedures, and instruction in the use of adaptive equipment).
97110 (therapeutic exercises) – Therapeutic exercise to develop strength and endurance, range of motion, and flexibility: active, active-assisted or passive (e.g., treadmill, isokinetic exercise, lumbar stabilization, stretching, strengthening). The exercise may be reasonable and medically necessary for a loss or restriction of joint motion, strength, functional capacity or mobility that 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, levels of assistance). This therapeutic procedure is measured in 15-minute units with therapy sessions frequently consisting of several units.
