General Guidelines for Therapeutic Procedures 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97545, 97546

   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. 

Specific Modality Guidelines G0283, 97012,97016,97018, 97022,97036, 97028, 97032, 97034, 97039

The following clinical guidelines pertain to the specific modalities listed.

G0283 – This modality includes the following types of electrical stimulation: 

•    Transcutaneous Electrical Nerve Stimulation (TENS). 

•    Microamperage E-Stimulation (MENS). 

•    Percutaneous Electrical Nerve Stimulation (PENS). 

•    Electrogalvanic stimulation (high voltage pulsed current). 

•    Functional electrical stimulation. 

•    Interferential current/medium current.

These types of electrical stimulation may be necessary during the initial phase of treatment, but there must be an expectation of improvement in function. Electrical stimulation must be utilized with appropriate therapeutic procedures (e.g., 97110) to effect continued improvement.

Electrical stimulation is typically used in conjunction with therapeutic exercises. It is expected this modality will be used in a clearly adjunctive role and not as a major component of the therapeutic encounter. 

When electrical stimulation is used for muscle strengthening or retraining, the nerve supply to the muscle must be intact. It is not medically necessary for completely denervated motor nerve disorders in which there is no potential for recovery or restoration of function. 

97012 (mechanical traction) – This modality, when provided by physicians or independent PTs, is typically used in conjunction with therapeutic procedures, not as an isolated treatment; however, it may be used in weaning an acute patient to a self-administered home program.

97016 (vasopneumatic device therapy) – Education for the home use of a lymphedema pump is sometimes provided by the lymphedema pump supplier. If the supplier does not provide this education, limited therapy professional visits for such purposes are allowable. Medicare does not expect to be routinely billed for repeated lymphedema treatments. Medicare expects that documentation in the physician’s medical record must support the necessity of repeated services.

How to submit claims for physician or NP or Physical or Occupational Therapist (PT or OT) or Speech-Language Pathologist (SLP) - In therapy billing

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.

General Modality Guidelines (Codes 97012, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039)

THERAPY SERVICES (PT, OT, SLP) (L32710)

Coverage Guidance

Coverage Indications, Limitations, and/or Medical Necessity

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by this entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

The cornerstones of rehabilitative therapy are mobilization, education and therapeutic exercise. The goal of rehabilitative medicine is discernible, functional progress toward the restoration or maximization of impaired neuromuscular and musculoskeletal function. To that end, the dynamic component of therapy, mobilization and patient education should predominate. Passive modalities should be used in the “warm-up” phase of the patient encounter as preparation for or as an adjunct to therapeutic procedures, and in the “cool-down” phase for reduction of pain, swelling and other post-treatment syndromes. Though passive modalities may predominate in the earlier phases of rehabilitation where the patient’s ability to participate in therapeutic exercise is restricted, Medicare expects these modalities to never be the sole or predominant constituent of a therapy plan of care. Further, Medicare expects the patient’s record to clearly reflect medical necessity for passive modalities, especially those that exceed 25 percent of the cumulative service hours of rehabilitative therapy provided for any beneficiary under a plan of care. 

Complicating factors that may influence treatment, e.g., they may influence the type, frequency and/or duration of treatment, may be represented by diagnoses by patient factors such as age, severity, acuity, multiple conditions, co-morbidities, and motivation; or by the patient’s social circumstances, such as the support of a significant other or the availability of transportation to therapy. 

In more refractory cases, the practitioner will support the need for continued care with documentation that clearly outlines the factors that affect the rate of recovery and reinforces the anticipation that further functional gain is expected. The contractor recognizes variability in strength, recovery time and the ability to be educated, and allows for a recertification for additional therapy, as long as adequate medical documentation by the supervising physician or therapist is recorded in the medical record and the patient continues to demonstrate progress. 

In all cases, whether the duration and intensity of rehabilitative services rendered are limited or extensive, Medicare expects the patient’s medical record to clearly demonstrate medical reasonableness and necessity for all therapy services, both active and passive. If an individual’s expected rehabilitation potential is insignificant, or the patient’s maximum rehabilitation potential have been realized, therapy is not reasonable and necessary and should not be reported to Medicare as a payable service.

Though this LCD establishes limitations to duration and intensity of outpatient rehabilitation, Medicare expects that most patients will not require maximum numbers of services. Providing maximal services as a routine is of concern and will result in Medicare auditing. 

Physical Therapy Plan of Care Requirements

The Centers for Medicare & Medicaid Services (CMS), is continuing to focus on lowering the Comprehensive Error Rate Testing (CERT) claims paid error rate. Currently, one area of concern identified in the CERT data is denial of outpatient rehabilitation therapy services due to missing physician/non-physician practitioner signature and dates on the certification of the plan of care. This has led to Novitas Solutions, Inc recouping overpayments totaling over $164.70. More importantly, when CMS and CERT extrapolate these errors to the universe they will account for approximately $19.3 million in claims payment errors for the November 2011 report.

Medicare defines rehabilitative services as those services that lead to "recovery or improvement in function and, when possible, restoration to a previous level of health and well-being."

Outpatient rehabilitation therapy services must relate directly to a written treatment plan (also known as the plan of care or plan of treatment).  Medicare states "The plan of care shall contain, at minimum, the following information: diagnoses, long term treatment goals, and type, amount, duration, and frequency of therapy services."

The plan of care is established by a physician, non-physician practitioner, physical therapist, an occupational therapist, or a speech-language pathologist  The signature and professional identity of the person who established the plan of care and the date it was established must be documented within the plan of care.  The plan of care must be established before the therapy treatment can begin.

Establishing the plan of care is different than certifying the plan of care.  Medicare states that certification of the plan of care requires a dated signature on the plan of care, or some other document, by the physician or non-physician practitioner who is the primary care provider for the patient.  In the absence of a formal certification document, a physician progress note indicating the physician's agreement with the plan of care is acceptable. The certification of the plan of care should occur as soon as possible after it is established or within 30 calendar days of the initial therapy treatment.  Payment may be denied if the physician does not certify the plan of care; therefore, the therapist should forward the plan to the physician as soon as it is established. Recertification of the plan of care, which also requires a physician or non-physician signature and date, should occur whenever there is a significant change in the plan or every 90 days from the initial plan of care certification.  A therapy provider, per Medicare, may obtain a verbal order for certification or recertification of the plan of care; however, the verbal order must be signed and dated by the physician/non-physician practitioner within 14 calendar days.