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Coverage criteria policies

Physical and occupational therapy - rehabilitative

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required. However, services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial may result if criteria are not met.

  • Athletic Trainer (AT) visits count towards Physical Therapy (PT) limits.
  • Occupational Therapy (OT) visits count towards Physical Therapy (PT) limits unless modifier ‘GO’ is used when billing.

Coverage

The treating Occupational Therapist or Athletic Trainer must obtain orders from practitioners licensed in medicine, osteopathy, chiropractic, podiatry, advanced practice registered nursing, or dentistry, or a physician assistant according to their professional practice standards and applicable state laws. PT and OT and AT visits are covered subject to the indications listed below and per your plan documents.

Cognitive rehabilitation is outside the scope of this policy. Please see related content at right for link to policy.

Indications that are covered

To be eligible for coverage, all rehabilitative therapies must meet the criteria below:

  1. Require the skills of a licensed physical therapist (PT), a licensed occupational therapist (OT), a therapy assistant, or an Athletic Trainer (AT).
  2. Be rehabilitative (see definitions) in nature and provided to a member whose functional status is expected to progress toward or achieve the objectives in the member’s plan of care within a 60 day period.
  3. Be provided in an outpatient hospital, physician clinic, community and public health clinic, or rehabilitative agency. Refer to the “Home Health Services” coverage criteria for PT/OT coverage criteria in a home setting.
  4. Passive therapies, including massage therapy, (see definitions) are only covered in conjunction with active therapies, not as stand-alone treatments.
To be eligible for physical or occupational therapy services for rehabilitation, the following criteria must be met:
  1. Rehabilitative therapy is required to address loss of function due to illness and/or injury as identified in the evaluation.
  2. PT/OT evaluations to determine need for therapy which includes the following:
    1. Evaluation of progress to date and assessment of:
      1. Ability to learn further task oriented therapeutic activities designed to significantly improve, develop or restore physical or sensory functions lost or impaired as a result of a disease or injury; or
      2. Ability to learn or relearn daily living skills or compensatory techniques to improve the level of independence in the activities of daily living (ADLs).
      3. Whether the treatment is resulting in progressive improvement as documented by:
        1. Decreased distribution, frequency or intensity of symptoms;
        2. Objective clinical findings are progressively improving, as evidenced by resolution or objectively measured improvement in physical signs of injury and less restrictive limitations on activity.
    2. Measurable goals for continued therapy.

Indications that are not covered

  1. Group therapy
  2. Educational therapy
  3. Therapy to improve social skills
  4. Therapy when measurable functional improvement is not expected or progress has reached a plateau
  5. Vocational and community reintegration services
  6. Maintenance therapy
  7. Recreational or vocational therapy including therapy for instrumental activities of daily living (IADLs)
  8. Custodial services
  9. Services not designed to improve or maintain the functional or sensory status of a member with a physical impairment
  10. Passive therapies, such as massage therapy, as stand-alone treatments
  11. Open swimming / exercise programs
  12. Whirlpool therapy that is not part of a physical or occupational therapy regimen/program for treatment of a medical condition
  13. PT/OT/ AT care not performed or supervised by a licensed PT or OT or medical practitioner, per licensure requirements
  14. Equine or hippotherapy (horse riding therapy)
  15. Hot & cold packs
  16. Massage therapy if provided by a massage therapist or any provider other than a PT, OT, AT or chiropractor.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

The following codes may be covered:

Codes

Description

95831

Muscle testing, manual (separate procedure) with report; extremity (excluding hand) or trunk

95832

Muscle testing, manual (separate procedure) with report; hand, with or without comparison with normal side

95833

Muscle testing, manual (separate procedure) with report; total evaluation of body, excluding hands

95834

Muscle testing, manual (separate procedure) with report; total evaluation of body, including hands

95851

Range of motion measurements and report (separate procedure); each extremity (excluding hand) or each trunk section (spine)

95852

Range of motion measurements and report (separate procedure); hand, with or without comparison with normal side

97005

Athletic training evaluation

97006

Athletic training re-evaluation

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 (e.g., 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

97039

Unlisted modality (specify type and time if constant attendance)

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)

97139

Unlisted therapeutic procedure (specify)

97140

Manual therapy techniques (e.g., mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

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 (i.e., 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 (e.g., 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 (i.e., 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 (e.g., 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 (i.e., 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 assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., 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.

97169

Athletic training evaluation, low complexity, requiring these components: A history and physical activity profile with no comorbidities that affect physical activity; An examination of affected body area and other symptomatic or related systems addressing 1-2 elements from any of the following: body structures, physical activity, and/or participation deficiencies; and Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 15 minutes are spent face-to-face with the patient and/or family.

97170

Athletic training evaluation, moderate complexity, requiring these components: A medical history and physical activity profile with 1-2 comorbidities that affect physical activity; An examination of affected body area and other symptomatic or related systems addressing a total of 3 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies; 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.

97171

Athletic training evaluation, high complexity, requiring these components: A medical history and physical activity profile, with 3 or more comorbidities that affect physical activity; A comprehensive examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures, physical activity, and/or participation deficiencies; 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.

97172

Re-evaluation of athletic training established plan of care requiring these components: An assessment of patient's current functional status when there is a documented change; and A revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome with an update in management options, goals, and interventions. Typically, 20 minutes are spent face-to-face with the patient and/or family.

97530

Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes

97535

Self-care/home management training (e.g., 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 by provider, each 15 minutes

97542

Wheelchair management (e.g., assessment, fitting, training), each 15 minutes

97750

Physical performance test or measurement (e.g., musculoskeletal, functional capacity), with written report, each 15 minutes

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

97761

Prosthetic training, upper and/or lower extremity(s), each 15 minutes

97799

Unlisted physical medicine/rehabilitation service or procedure

The following codes are not covered:

Codes

Description

97545

Work hardening

97546

Work hardening – additional hour

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Definitions

Active treatment - requires active patient participation in a therapeutic program to increase flexibility, strength, endurance, or awareness of proper body mechanics.

Activities of daily living (ADLs) - everyday activities such as eating, bathing, dressing, toileting, transferring, continence, dressing, personal hygiene and mobility necessary to achieve these activities.

Athletic Trainers (ATs) - health care professionals who collaborate with physicians to provide preventive services, emergency care, clinical diagnosis, therapeutic intervention and rehabilitation of injuries and medical conditions. (NATA National Athletic Trainers’ Association)

Custodial care-supportive services focusing on activities of daily life that do not require the skills of qualified technical or professional personnel, including but not limited to, bathing, dressing, and feeding.

Functional skills - essential activities of daily life common to all members such as dressing, feeding, ambulation, transfers and fine motor skills. Measurable progress emphasizes mastery of functional skills and independence in the context of the member's potential ability as specified within a care plan or treatment goals.

Instrumental activities of daily living (IADLs) - activities related to independent living, such as cleaning, using a telephone, shopping, laundry, managing medications, transportation and managing money.

Maintenance care - non-rehabilitative care and supportive services, including skilled or non-skilled nursing care for a member whose condition has not significantly improved or deteriorated over a measurable period of time (generally a period of time of two months from establishing a functional goal).

Occupational therapy (OT) –Therapy to help people across the lifespan participate in the things they want and need to do through the therapeutic use of everyday activities (occupations) performed by occupational therapists and occupational therapy assistants. (AOTA American Occupational Therapy Association)

Passive treatment – manual therapy techniques which include but are not limited to: mobilization and manipulation, manual lymphatic drainage, manual traction, myofascial release, massage therapy (97124), thermal treatment, electrical muscle stimulation, braces, manual and mechanical therapy, and adjustments.

Physical therapy (PT) - the examination, treatment, and instruction of persons in order to detect, assess, prevent, correct, alleviate, and limit physical disability and bodily malfunction performed by a licensed physical therapist or physical therapy assistant. (APTA-American Physical therapy Association)

Rehabilitative therapy – Therapy provided by a PT,OT or AT as a restorative service, provided for the purpose of obtaining significant functional improvement, within a predictable period of time, (generally within a period of two months) toward a patient’s maximum potential ability to perform functional daily living activities.

Vocational- therapy related to performing or enhancing one’s occupation or work

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Occupational Therapy Association. (2015). Standards of practice for occupational therapy. American Journal of Occupational Therapy, 69(Suppl. 3), 6913410057. http://dx.doi.org/10.5014/ajot.2015.696S06
  2. American Physical Therapy Association (APTA) (2006). Standards of Practice for Physical Therapy. HOD S06-13-22-15. Updated: 10/1/13. Accessed September 28, 2017.) Available at URL address: http://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/Practice/StandardsPractice.pdf.
  3. Baird, L. C., Klimo, P. Jr., Flannery, A. M., Bauer, D. F., Beier, A., Durham, S., … Mazzola, C. (2016). Congress of Neurological Surgeons systematic review and evidence-based guideline for the management of patients with positional plagiocephaly: the role of physical therapy. Neurosurgery, 79(5), E630-1.
  4. Delitto, A., George, S. Z., Van Dillen, L. R., Whitman, J. M., Sowa, G., Shekelle, P., … Godges, J. J. Low back pain. (2012). Journal of Orthopaedic & Sports Physical Therapy, 42(4), A1-A57.
  5. Hayes, Inc. Hayes Medical Technology Directory Report. Hippotherapy for neuromusculoskeletal dysfunction. Lansdale, PA: Hayes, Inc.; August, 2009. Reviewed August, 2013. Archived September, 2014.
  6. Hayes, Inc. Hayes Technology Brief. Aquatic therapy for mobility impairment in children. Lansdale, PA: Hayes, Inc.; July, 2012. Reviewed June, 2014. Archived August, 2015.
  7. Hooten, M., Thorson, D., Bianco, J., Bonte, B., Clavel Jr., A., Hora, J., … Walker, N. Institute for Clinical Systems Improvement. Pain: assessment, non-opioid treatment approaches and opioid management. Updated August 2017.
  8. Kaplan, S. L., Coulter, C., & Fetters, L. (2013). Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics of the American Physical Therapy Association. Pediatric Physical Therapy, 25(4), 348-94.
  9. Moyers, P. A. (1999). The guide to occupational therapy practice. American Journal of Occupational Therapy, 53, 247-322. doi:10.5014/ajot.53.3.247.
  10. National Institute for Health and Care Excellence. (2016). Cerebral palsy in under 25s: assessment and management. NICE guideline (NG62).
  11. Patterson, M. C. Management and prognosis of cerebral palsy. In: UpToDate, Bridgemohan, C. (Ed), UpToDate, Waltham, MA. (Accessed on September 28, 2017.)